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European Journal of Radiology 59 (2006) 359–366

MDCT in blunt intestinal trauma

Stefania Romano a,∗, Mariano Scaglione a, Giovanni Tortora a, Antonio Martino b,Francesco Di Pietto a, Luigia Romano a, Roberto Grassi c

a Department of Diagnostic Imaging, “A.Cardarelli” Hospital, 80131 Naples, Italyb Trauma Center, “A.Cardarelli” Hospital, 80131 Naples, Italy

c Department “Magrassi-Lanzara”, Section of Radiology, Second University of Naples, 80138 Naples, Italy

Received 21 May 2006; accepted 24 May 2006

bstract

Injuries to the small and large intestine from blunt trauma represent a defined clinical entity, often not easy to correctly diagnose in emergencyut extremely important for the therapeutic assessment of patients. This article summarizes the MDCT spectrum of findings in intestinal bluntesions, from functional disorders to hemorrhage and perforation.

2006 Elsevier Ireland Ltd. All rights reserved.

eywords: Intestine; Trauma; MDCT; Abdomen; CT; Trauma

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. Introduction

Intestinal mesenteric injuries are found in approximately% of all patients undergoing laparotomy after blunt abdom-nal trauma [1]. About 1.3% of patients with blunt abdominalrauma presents bowel injuries, that are frequently associatedith abdominal solid organs lesions [2]. Mainly, there are three

ypes of injuries: crush, shearing forces at fixed sites of attach-ent, burst injuries from increase in endoluminal pressure [2].These lesions are related to a high morbidity and mortality,

epresenting a diagnostic dilemma either from trauma surgeonsnd emergency physicians [3]. Actually, a non-operative man-gement is often the treatment of choice for abdominal solidrgans lesions from trauma [4], however because missed bowelnd mesenteric injuries are possible [4], early diagnosis andreatment are critical to increased the survival rate [5].

Computed tomography (CT) has been initially proposed inhe past two decades in the acute clinical setting of patients withbdominal blunt trauma suspected to have bowel and mesenteric

esions, becoming the primary modality for the imaging in theseases [5–9].

∗ Corresponding author at: Via G.Fava 28 parco la piramide, 80016 Maranoi Napoli, Italy. Tel.: +39 0817426089.

E-mail address: stefromano@libero.it (S. Romano).

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720-048X/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.ejrad.2006.05.011

. MDCT technique

In the recent past years, helical CT was considered a sensi-ive tool in the identification of bowel and mesenteric injury afterlunt trauma, providing a wide spectrum of findings [10]. Multi-etector row CT (MDCT) examination without oral contrastaterial seems adequate for depiction of bowel and mesen-

eric injuries that require surgical repair [11]. Because of themproved image quality provided by the new generation of scan-ers, results are comparable with previously reported data foringle-detector row helical CT with oral contrast material [11].he acquisition of initial scans without oral contrast materialeems to help to meet criteria of safety and efficiency withoutacrificing diagnostic accuracy [11].

Pre-contrast abdomino-pelvis scans (5 mm slice thickness)re useful to better characterize the attenuation values of organsnd structures in order to detect or rule out hemorrhagic phe-omena and to evaluate any post-contrast HU abnormal changes.biphasic study in arterial and venous phase is indicated espe-

ially when active bleeding or major vessels trauma are clinicallyuspected. In suspicion of low-flux vascular extravasation frominor vessels, a delayed phase may be added to the exam-

nation protocol. Acquisition parameters using an optimisedatio between slice thickness and reconstruction interval (i.e.:/3 mm acq., back recon. 1/1 mm), may allow a targeted multi-lanar reconstruction in the post-processing elaboration.

360 S. Romano et al. / European Journal of Radiology 59 (2006) 359–366

Fig. 1. In a middle aged patient with blunt torso trauma and thoracic injury (a), intestinal entero-enteric non-obstructive intussusception (b) was noted, not associatedt a aftc 1 da

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o parenchymal organs injury. Following MDCT control at 48th hour from traumonfirmed the finding (c). Resolution of the event was appreciable starting from

. Spectrum of MDCT Findings

Computed tomographic findings of bowel injury from bluntrauma include extraluminal free peritoneal or retroperitonealir, visualization of direct tears in the bowel wall, intra-peritonealr retroperitoneal free or collected fluid, bowel wall thickening,bnormal bowel wall enhancement, mesenteric infiltration orematoma, extravasation of enteric or vascular contrast medium,leus [12,13]. Bowel wall thickening as well as mesenteric infil-ration and free intra-peritoneal air seem to be more relevantredictors of bowel injury [13].

.1. Functional disorders

Intestinal distension by fluid without evidence of an effectiveite of obstruction may be observed in patients with blunt abdom-nal trauma, although it can be related to intramural hematomahat in rare cases may cause an intussusception of the intestine14], often as a non-occlusive and transient event (Figs. 1 and 2).leus is a less effective predictor of bowel injury from bluntrauma than other more sensitive and specific findings [13], how-ver intussusception from functional disorders caused by trauma

equires monitoring to exclude progression of the transient dis-ase into a confirmed intestinal obstruction [15], preferablyith abdominal plain film. MDCT-enteroclysis may be an addi-

ional useful follow-up technique to study a trauma-related small

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er administration of endoluminal contrast medium through naso-duodenal tubey later (d).

ntestine disease in the hemodynamically stable conservativelyreated patient, to rule out an obstructive lesion, resulting in someases resolutive for transient disorders (Fig. 1).

.2. Bowel wall thickening

Bowel wall thickening was seen in 60–75% of cases of bowelnjury and in 8% of patients with other injuries [5,6,13] and iteems to be more sensitive for bowel injury than free peritonealir or extravasation of oral contrast medium [5,6]. However,valuation of this finding can be subjective, with wall thicknessuperior to 3–4 mm considered as abnormal [6,17,18], whereasost of contributions reported in literature seems not to consider

he luminal distension. To assess a bowel wall abnormality inatients with blunt abdominal trauma, some authors suggestedo consider the disproportionate thickening of the intestine com-ared to normal appearing tracts or a bowel wall thickness supe-ior to 3 mm with adequate distension of the lumen [5]. Bowelall thickening from intramural hematoma is a known evidencef blunt traumatic injury. Frequently only retrospectively diag-osed, it can be noted in all intestinal segments, although if theolon localization is rare, generally conservatively treated with

pontaneous resolution [19]. The healing time of an intramu-al or a perivisceral hematoma may be various, in some casesith delayed complications: a duodenal intramural hematoma

rom blunt trauma resolved 48 days after trauma in a 14-year-old

S. Romano et al. / European Journal of Radiology 59 (2006) 359–366 361

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ig. 2. A 75-year-old patient with thoracic (a) and pelvic (b) lesions from bpontaneously recovered without symptoms or obstruction.

oy [20], whereas a case of intra-mesenteric traumatic cyst andbrosis around the duodenum resulting in duodenal obstructionyears after injury [21].

.3. Abnormal wall enhancement

The increased small bowel enhancement has been described

s consequence of shock in trauma, in which the intestine isypoperfused, with increased permeability and parietal thick-ning and hyperdensity as a consequence of interstitial leakf contrast medium [22]. Distension of the involved intestinal

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Fig. 3. Small transverse mesocolon hematoma (arrow in a) from bl

auma. A colo-colic intussusception was appreciable (c). The transient event

egment is related to the accumulation of intraluminal fluid, pre-umably due to failed resorption capability [22]. It is importanto note that these findings related to hypoperfusion cannot beoted in large bowel, suggestive of the lower oxygen demand orless efficient shunting of blood away from this intestinal tract

22]. Evaluation parameters for wall enhancement may be theeference to the psoas muscle or that of adjacent vessels atten-

ation [23]. The isolated hyperdensity of the intestinal mucosarom blunt abdominal injury has been reported [5]. In presencef a major accident, the absence of reperfusion may lead to arauma-related intestinal infarction.

unt trauma in a 61-year-old patient with thoracic injuries (b).

362 S. Romano et al. / European Journal of Radiology 59 (2006) 359–366

Fig. 4. A 22-year-old man with blunt abdominal trauma, without any parenchymal organs lesion. The first MDCT examination showed evidence of free peritoneal fluid( atientw row is in b).

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arrows in a and b) without peritoneal free air (c). Twenty-four hours later the pas noted (d), with free bubble gas close to an ileal segment in left abdomen (ar

ame loop of small intestine at the previous CT examination (segmented circle

.4. Mesenteric stranding

Mesenteric stranding is reported in literature as associatedith mesenteric injury with or without bowel perforation [5]:

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underwent a new MDCT examination for acute abdomen: pneumoperitoneumn e), better evident on the coronal view (arrow in f). Note the appearance of theSurgery confirmed the presence of ileal perforation.

n fact, some investigators reported that mesenteric infiltrationas been seen in 68% of patients with bowel injury, but also in3% with other abdominal injuries [13]. However association ofhis finding with increased bowel wall thickness may be highly

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S. Romano et al. / European Jou

uggestive for a major intestinal injury [5,18]. When the bowelhows no significant abnormalities but there is evidence of aesenteric hematoma (Fig. 3), diagnosis of an isolated mesen-

eric vessel lesion should be suggested [5].

.5. Fluid in peritoneal/retroperitoneal recesses

The evidence of free peritoneal fluid in absence of traumaticesion to abdominal solid organs seems to be suggestive of bowelr mesenteric laceration [5], however in this case it is mandatoryo evaluate the presence of other additional findings predic-ors of bowel injury, such as the abnormal bowel thickening or

he pneumoperitoneum (Fig. 4). Free intra-peritoneal oral con-rast presents high specificity for bowel perforation [5], whereasetroperitoneal peri-duodenal hematoma may be considered apecific sign of duodenal injury [5].

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ig. 5. A 23-year-old patient with pelvic fracture (arrow in a) from trauma and consnd pneumoperitoneum (arrow in c).

f Radiology 59 (2006) 359–366 363

.6. Parietal laceration and discontinuity

Discontinuity of bowel wall may be difficult to note andiagnosis of intestinal laceration is essentially based on sec-ndary findings [5]. However, because additional findings suchs the distribution of the free air may be a clue to the site ofn injured intestine [24], MDCT multi-planar reconstructionsrom isotropic data set may allow an optimal visualization of thentestinal wall in case of parietal laceration from blunt traumaFigs. 5 and 6).

.7. Free peritoneal/retroperitoneal air

Free peritoneal or retroperitoneal air has a sensitivity of4–55% [5,16,17] in indicating a bowel perforation, however

equent burst injury of the caecum (b), with evidence of perivisceral hematoma

364 S. Romano et al. / European Journal of Radiology 59 (2006) 359–366

Fig. 6. In a 40-year-old patient with complex pelvic fracture (a), evidence of a right colon traumatic herniation (b) was noted. Conspicuous emphysema of the softt le inr : noteM

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issue was also present (c and d). A dislocated osseous fragment was appreciabeconstruction (e). Surgery confirmed the presence of right colon laceration (f)

DCT images.

arotraumas and mechanical ventilation can results in air below

he diaphragm [5,25]. Early detection of traumatic injury ofhe intestine is often not easy, but repeated examinations aftereveral hours may reveal an increased amount of free air [5]Fig. 4).

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the region of intestinal herniation (d), better evident at coronal thick slab MIPthe evidence of the small osseous interposed fragments already appreciated at

.8. Extravasation of contrast medium

Extravasation of endoluminal contrast and free peritoneal airave been reported to be usually seen in case of bowel rup-ure [13], whereas extravasation of mesenteric vascular contrast

S. Romano et al. / European Journal of Radiology 59 (2006) 359–366 365

Fig. 7. A 25-year-old man with thoraco-abdominal trauma from car crash. No evidence of abdominal parenchymal organ injuries or peritoneal fluid at admission.Two days later, presence of bloody diarrhea. Patient underwent endoscopic examinations of the colon and stomach, but no source of hemorrhage was found. MDCTp minalb rgery.

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erformed with i.v. contrast enhancement without administration of any endoluetter evident at MPR (b) and MIP (c) coronal reconstructions, confirmed at su

edium seems to be appreciable only in case of proven bowelr mesenteric injury (16%) [13]. In case of endoluminal hemor-hage, MDCT may be an useful tool to detect extravasation inhe intestinal segment especially when conventional endoscopyannot be used as diagnostic approach (Fig. 7).

. Summary

For the prospective CT diagnosis of bowel injury, CT had aeported sensitivity of 64%, an accuracy of 82% and a specificityf 97% [13].

Relevant predictors of bowel injury included mesenteric infil-ration, bowel wall thickening, extravasation of vascular ornteric contrast agent and the presence free air [13]. In a ret-ospective blinded review of patients with bowel injury, CT

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contrast, showed mucosal hyperdensity from hemorrhage of a jejunal loop (a),

howed good to excellent inter-observer reliability for individualT signs as well as for diagnosis of bowel and visceral injuries.owever, it seems that experience plays a great role for a correctiagnosis: faculty radiologists tended to diagnose injuries withreater accuracy and confidence, but they showed significantlyetter performance than residents only in diagnosing duodenalerforation [13]. Moreover, performance was lower for faculty,enior radiologists and young residents in detection of stomachnd colon injury and for the detection of hematoma of jejunumnd ileum [13]. It can be hypothesized that it can occurs becauseither stomach and colon cannot follow the same wall semeiotics

n damage from blunt trauma respect to the small bowel. How-ver, no individual CT sign can be considered both sensitive andpecific for bowel or mesenteric injuries [13]. In these cases, theey to afford the correct diagnosis should be also to consider the

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66 S. Romano et al. / European Jou

ventual presence of lesions to abdominal solid organs, in ordero accurately detect the nearby territory, searching for additionalnjury to hollow viscera and mesentery.

In conclusion, whereas helical CT scanning was very accu-ate in detecting bowel and mesenteric injuries, as well as inetermining the need for surgical exploration in bowel injuries7], the latest generation of CT with multi-detector row technol-gy seems to be more sensitive and specific than other imagingechniques in detection of bowel and mesenteric injuries [12].owever, a correct diagnosis of intestinal damage from blunt

bdominal trauma may be effected considering the presence ofne or more signs from the entire spectrum of findings, corre-ating the imaging to the clinical evidence.

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