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Mr. Shashi Prakash
M. Sc. Nursing II Year
 The bowel and the mesentery represent the structures most
frequently involved in blunt abdominal trauma (BAT) after the liver and
the spleen.
 The relative infrequency of such injuries, explains the high rates of
delayed and missed diagnoses.
 Delayed diagnosis of bowel and mesenteric injuries, by as few as 8 h,
may result in severe complications and high mortality rates, mainly
related to bleeding, peritonitis, and sepsis.
 In the current era of non-operative management of patients with BAT,
the radiologist is not only asked to detect signs of intestinal and
mesenteric traumatic injuries but also to formulate a clinical degree of
severity of such lesions, identifying those requiring an immediate
operative treatment (angiography or surgery), substantially
represented by intestinal perforation, active bleeding, and vascular
avulsion of the mesentery, resulting in septic, hemorrhagic, and
ischemic complications
 Small bowel injuries
 Most common site of hollow viscus injury
 Majority in penetrating trauma, up to 60%
 Less than 1% of all trauma admissions
 1.1% of admissions after blunt injury
 2.9% patients undergoing abdominal workup (CT, abdominal ultrasound,
diagnostic peritoneal lavage, exploratory laparotomy)
 0.3% of all blunt trauma patients have perforated small bowel injury
 Duodenal injuries
 6.7% in penetrating abdominal cases, 0.1% blunt abdominal trauma
 12% of blunt hollow viscus injuries
Colon: usually due to penetrating trauma
Second most commonly injured organ in penetrating
abdominal injury
20% patients with penetrating abdominal trauma and
7% patients with pelvic gunshot wounds have rectal injury
0.3%-5% among blunt trauma
1. Mesentery
Proper
2. Transverse
mesocolon
3. Sigmoid
mesocolon
 Most common: small bowel (70 %).
 In particular, proximal jejunum near the ligament of Treitz, distal ileum near the
ileo-cecal valve, intestinal segments close to adhesions are mostly exposed to
damage being close to points of anatomical or constituted fixity, where mobile
and fixed portions of the gut are contiguous and, therefore, susceptible to
shearing force.
 Colon injury from BAT is uncommon (20 %), being diagnosed in about 0.5 % of
all major blunt traumas and in 10.6 % of patients undergoing laparotomy.
 Most of colonic injuries are “partial-thickness” (only 3 % of patients undergoing
laparotomy have “full-thickness” colonic tears).
 The ascending and descending colon, fixed, partially retroperitoneal segments,
are generally exposed to more severe injuries compared to the transverse and
the sigmoid colon, wrapped in their own meso and, therefore, characterized by a
certain mobility. The duodenum represents the structure less frequently involved
in blunt intestinal and/or mesenteric trauma .
Road traffic accidents (RTA, 70–85 %), aggressions and falls from heights.
With regard to RTA, an increase in intestinal and/or mesenteric lesions has been registered after
the introduction of seat belts, which compress the intestinal loops at impact creating a “closed”
hollow viscus and cause a sudden increase of the intraluminal pressure resulting in bursting
injuries.
The presence of a “seat belt mark” sign is not surprisingly considered a reliable predictor of
bowel injury.
• The incidence of BIMT is significantly higher in childhood, (impact of the bicycle’s handlebar against the abdominal
wall)
Pathogenic mechanisms at the basis of BIMT are substantially three: acting, isolated or
combined: –
• Abdominal pain (often severe and diffuse)
• Abdominal distention
• Severe abdominal cramping
• Bloating, Nausea and vomiting
• Rigidity, Guarding
• Lack of bowel sounds, paralytic ileus
• Rectal bleeding
• Fever (usually not immediately)
• Chills
• Fatigue
• Rebound tenderness.
Objective data
Clear clinical signs of peritonitis
have late onset (may not appear
for hours), especially in the case
of traumatic perforation of the
small intestine, whose content is
characterized by neutral pH, low
bacterial charge, and weak
enzymatic activity
Symptoms can be hidden or
attenuated by concomitant
injuries, as in the case of major
trauma or neurological
impairment due to involvement
of the head or spinal cord, or by
medications which can mask
pain and guarding
The attention for suspicious
signs from the gastro-intestinal
tract can be reduced by
coexisting, distracting lesions,
such as a femur fracture
Clinical assessment alone as the indication for laparotomy to treat bowel or
mesenteric injuries is associated with a negative laparotomy
rate that may be as high as 40 %
 Inspection; Penetrating and Blunt Trauma
 Percussion
 Auscultation
 Blood tests
 Plain X-ray
 Ultrasound (FAST)
 CT Scan
 Diagnostic Laparoscopy
 Diagnostic Peritoneal Lavage
Traumatic
Bowel Injuries
Major
“full-thickness” tear of the
intestinal wall resulting in the
spillage of enteric contents
into the abdominal cavity
Minor
incomplete tears of the
intestinal wall, intramural
hematomas, and parietal
contusions; are now widely
managed non-operatively
SPECIFIC
 Interruption of the bowel wall
 Extraluminal air/contrast
 Extraluminal spillage of enteric
contents
 Intramural hematoma
 Intramural air
 Bowel wall defect
NON SPECIFIC
 Extraluminal air collection
(intraperitoneal, mesenteric or
retroperitoneal)
 Intraperitoneal fluid
 Bowel wall thickening
 Abnormal bowel wall
enhancement
ABDOMINAL STAB WOUNDS.
Gross pathology
Fresh stab wound of the colonic wall
FRESH STAB WOUND OF THE TRANSVERSE COLON
(GROSS PATHOLOGY)
CASE CONTRIBUTED BY DR HENRY KNIPE
Presentation
Abdominal stab wounds.
Patient Data
Age: 42 years
Gender: Female
https://radiopaedia.org/cases/29961/play?lang=us
TRAUMATIC BOWEL PERFORATION AT THE
DUODENOJEJUNAL FLEXURE
CASE CONTRIBUTED BY DR ROBERT G
Presentation
Left upper abdominal pain after she fell off her bicycle and
was hit in the abdomen by the handlebar
Patient Data
Age: 25 years
Gender: Female
Patient Data
 Radiology Quiz 19450 | Radiopaedia.org
TRAUMATIC SMALL BOWEL PERFORATION:
HANDLEBAR INJURY
CASE CONTRIBUTED BY DR IAN BICKLE
Presentation
Fall from bicycle. Body hit the handlebars. Abdominal pain. No
distension.
Patient Data
 Age: 35 years
 Gender: Male
Patient Data
 https://radiopaedia.org/cases/58713/play?lang=us
TRAUMATIC SMALL BOWEL PERFORATION:
HANDLEBAR INJURY
CASE CONTRIBUTED BY DR IAN BICKLE
Presentation
Fall from bicycle. Body hit the handlebars. Abdominal pain. No
distension.
Patient Data
Age: 35 years
Gender: Male
Patient Data
 https://radiopaedia.org/cases/58713/play?lang=us
TRAUMATIC BOWEL INJURY
CASE CONTRIBUTED BY RMH CORE CONDITIONS
Presentation
Motor vehicle collision. Driver.
Patient Data
Age: 90 years
Gender: Male
https://radiopaedia.org/cases/26328/play?lang=us
TRAUMATIC SMALL BOWEL PERFORATION:
HANDLEBAR INJURY
CASE CONTRIBUTED BY DR IAN BICKLE
Presentation
Fall from bicycle. Body hit the handlebars. Abdominal pain. No
distension.
Patient Data
Age: 35 years
Gender: Male
Patient Data
 https://radiopaedia.org/cases/58713/play?lang=us
 https://youtu.be/mpJppPa_jsU
Bowel perforation at the ligament of Treitz in a 55-year-
old woman after a motor vehicle accident. (B) Axial
computed tomography image, showing a suspicious defect
(white arrow) with focal fluid and extraluminal air
(arrowhead) adjacent to the duodenojejunal junction. There
also is free pneumoperitoneum (black arrows). There is a
posttraumatic jejunojejunal intussusception (dashed
arrow).
1. Extraluminal
Air
2. Extraluminal
Contrast
3. Bowel-Wall
Defect
 Splenic lacerations and ileal perforation in
a 66-year-old woman involved in a motor
vehicle injury. (A) Axial contrast-enhanced
computed tomography (CT), revealing multiple
large splenic lacerations (arrows) with
hemoperitoneum (arrowheads)
 (B, C) Caudal CT sections, revealing an
ileal loop perforation (arrow in B) with
free extraluminal air (arrowhead in C).
There is a large hemoperitoneum
4. Extraluminal
Air
 (B) Caudal CT section, revealing a complete transection
at the junction of the D2 and D3 segments of the
duodenum (white arrows) with associated duodenal-wall
thickening and hematoma (black arrow). There also is a
traumatic right lateral abdominal wall hernia through
the diaphragmatic insertion with the hepatic flexure
seen in the hernial sac (arrowhead).
Bowel-Wall
Thickening
 A 31-year-old woman involved in a motor
vehicle accident, with active arterial
mesenteric bleed. (A) Axial-contrast computed
tomography, revealing extravasation of
contrast (arrow)
1. Injury to the
Mesenteric
Vasculature
(Appear as beading or
termination of vessels.
Beading appears as vessel
irregularity, whereas
termination is seen as
abrupt cutoff of the
mesenteric artery or vein)
2. Mesenteric
Extravasation
Traumatic
Mesenteric
Injuries
Major
active blood extravasation,
avulsion of the meso
resulting in intestinal
ischemia and full-thickness
tear of the meso, require
urgent operative treatment.
Minor
partial lacerations of the
meso, focal mesenteric
contusions, and the stable
mesenteric hematomas
SPECIFIC
Avulsion of the meso with
intestinal ischemia
Active blood extravasation
Mesenteric hematoma
NON-SPECIFIC
Mesenteric “infiltration”
Free abdominal fluid
 Little can be done for the patients with abdominal injuries in
the field.
 General features of stabilization and evaluation include
ensuring an adequately functioning airway, inserting i/v lines
in upper extremity, and beginning of fluid resuscitation.
 For penetrating wound sterile dressing should be applied.
 Any foreign body embedded in the trunk should not be
removed, as major bleeding may follow.
 Evisceration is best left undisturbed, except to apply a sterile
dressing and protect the patient from further injury.
 Proper position
 Early rapid transport
 Diagnosis: requires history, examination & investigation
 History
 Primary goal is to identify that injury exists, not necessary making an
accurate Dx
 History from prehospital care, or transferring team; vital signs, physical
assessment, prehospital course, and response to therapy should be
obtained.
 Mechanism of injury is important factor in making high index of
suspicion, so detailed history is helpful if available.
 In case of blunt trauma, determine
 The types of vehicles involved
 The speed they were traveling
 Collision patterns
 Use of seatbelts
 Air bag deployment
 The patient’s position in the vehicle
 In case of penetrating trauma by gunshot, determine
 Type of weapon used
 Number of shots
 Distance from victim
 Back pain associated with compression fracture of the upper limbs or
spinal region carries an associated 20% chance of renal injury.
 Associated symptoms
 Pain, vomiting, hematuria, hematochezia, dyspnea, respiratory
distress.
 Thus in combination with the aspects of physical diagnosis and
adjuncts to physical diagnosis as discussed below, fracture on the
lower left chest, there is a 20% chance of associated splenic injury, and
with rib fracture on the right there is 10% chance of liver injury.
 The ABCDE should be initiated.
 Patent air way, if necessary ETT with assisted ventilation should
begin particularly in comatose patients.
 Upper extremity, large bore I.V cannulas
 I.V fluids with RL should begin immediately
 Next, perform a rapid neurologic examination and assess head to
toe
 to identify obvious injuries and signs of
 prolonged exposure to heat or cold.
 If your patient sustained blunt trauma, as in a motor vehicle crash
(MVC), keep his neck and spine immobilized until X-rays rule out
a spinal injury.
 Vitals monitoring
 Blood sampling, for hematologic, biochemical, serologic investigations should be
carried out.
 ABGs, and are repeated to assess ventilatory status and acidosis.
 Control the patient’s pain without sedating him, so you can continue to assess his
injuries and ask him questions. Generally, I.V. analgesics such as morphine can
adequately manage pain without sedation.
 An early rapid assessment of the abdomen is performed.
 Insert a gastric tube to decompress the patient’s stomach, prevent aspiration, and
minimize leakage of gastric contents and contamination of the abdominal cavity.
This also gives you access to gastric contents to test for blood, the presence of
blood becomes indication for operation in penetrating trauma.
 Administer tetanus prophylaxis and antibiotics as ordered.
 Inspection, palpation, auscultation, percussion,
 Inspection: abrasions, contusions, lacerations, deformity,
entrance and exit wounds to determine path of injury.
 Grey-Turner sign
 Cullen sign
 Kehr sign
 Left shoulder pain while supine; caused by diaphragmatic
 Irritation (splenic injury, free air, intra-abdominal bleeding)
 Palpation: elicit superficial, deep, or rebound tenderness;
involuntary muscle guarding
 Percussion: subtle signs of peritonitis; tympany in gastric
dilatation or free air; dullness with hemoperitoneum.
 Auscultation: bowel sounds may b decreased(late finding).
Bluish discoloration of
lower flanks, lower back;
associated with
retroperitoneal bleeding of
pancreas, kidney, or pelvic
fracture.
Bluish discoloration
around umbilicus,
indicates peritoneal
bleeding, often pancreatic
hemorrhage
Abdominal-Wall Hernia
Diaphragmatic Hernia
Small-Bowel Intussusceptions
Posttraumatic Appendicitis
Abdominal Compartment Syndrome
 Trauma patients with severe intra-
abdominal injuries, presenting in profound
shock and requiring large amounts of
intravenous fluids are those most
susceptible to the development of sudden
increase in intra abdominal pressure.
 This syndrome is characterized by
abdominal distension, oliguria, hypoxia,
and increased pulmonary pressure.
 The diagnosis is confirmed by the
measuring the intra abdominal pressure
directly or the intravesical pressure.
 Renal failure
 Decreased urine output
 Respiratory failure
 Decrease compliance, increased pulmonary edema / airway pressure
 Cardiac failure
 Decreased cardiac output (decreased preload / increased after load)
 Visceral failure
 Dec blood flow to liver, bowel (bacterial translocation)
 Neurologic complications
 Increased intracranial pressure
 Abdominal wall “failure”
 Dehiscence, hernia formation
 Surgical abdominal
decompression
 Nonsurgical: paracentesis, NGT,
sedation
 Staged approach to abdominal
repair
 Temporary abdominal closure
 Ineffective breathing pattern related to injury to muscles as evidenced by breathing
pattern.
 Acute Pain related to trauma as evidenced by verbalization and facial expressions.
 Imbalanced nutrition less than body requirement related to injury as evidenced by intake
and output chart.
 Impaired skin integrity related to wound as evidenced by inspection and observation.
 Activity intolerance related to imbalanced nutrition and pain.
 Increased risk of hypovolemia and shock related to abdominal trauma and internal
bleeding.
 Increased risk of sepsis related to acute inflammatory process and peritonitis.
 Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or
inflammation.
 Anxiety related to the symptoms of disease and fear of death.
 Promote adequate respiratory and cardiovascular function.
 Provide measures for prevention of the shock and sepsis.
 Prevent avoidable injury and complications.
 If surgical intervention prescribed, prevent postoperative complications.
 Relief or diminish symptoms.
 Decreased anxiety with increased knowledge of disease, it treatment, and
follow-up.
Abstract
Purpose: Currently, nonoperative management is the procedure of choice for solid organ injury in patients with
a blunt abdominal trauma. Missed blunt bowel and mesenteric injuries (BBMIs) are possible because diagnosis
is difficult. The aim of our study was to test a new algorithm for BBMI diagnosis using abdominal
ultrasonography (AUS), computed tomography (CT), and diagnostic peritoneal lavage (DPL).
Methods: We reviewed cases of blunt abdominal injuries over a 10-year period, then we designed an
algorithm that was prospectively tested in hemodynamically stable patients over a 2-year period. An abnormal
AUS led to helical CT. When the CT showed more than 2 findings suggestive of BBMI, laparotomy was
performed. In case of 1 or 2 abnormal CT findings, we performed a DPL and calculated the ratio of white blood
cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid and divided this by the WBC/RBC
ratio in peripheral blood. A ratio of 1 or higher was considered positive for BBMI, and a laparotomy was
immediately performed. Patients with a ratio of less than 1 were managed nonoperatively.
Results: In the retrospective study, 26 (1%) of 2126 patients admitted to our trauma center for blunt trauma
had a BBMI, including 15 (58%) diagnosed after a median delay of 24 hours. In the prospective study, 531
patients were admitted for blunt trauma with multiple injuries, including 131 with abdominal trauma. Computed
tomography was performed in 40 patients. There were 2 criteria or more of BBMI in 1 patient, 0 criteria in 27
patients (with an uneventful follow-up), and 1 or 2 criteria in 12 patients who had DPL with a median ratio of
0.82 (ranges, 0.03-9). Five patients had a ratio of 1 or higher. They underwent immediate laparotomy. In all 5
cases, BBMI was found. The 7 patients who had a ratio of less than 1 were observed in ICU and treated for
extra-abdominal injuries. No BBMI injury was missed in these patients. The accuracy of the algorithm was
100% (95% confidence interval, 0.99-1.00).
Conclusion: The proposed algorithm (based on AUS, CT, and DPL) had a high accuracy to diagnose BBMI
while requiring the performance of DPL in only a few (2%) patients.
Abstract
Purpose: Currently, nonoperative management is the procedure of choice for solid organ injury in patients with a blunt abdominal trauma.
Missed blunt bowel and mesenteric injuries (BBMIs) are possible because diagnosis is difficult. The aim of our study was to test a new
algorithm for BBMI diagnosis using abdominal ultrasonography (AUS), computed tomography (CT), and diagnostic peritoneal lavage
(DPL).
Methods: We reviewed cases of blunt abdominal injuries over a 10-year period, then we designed an algorithm that was prospectively
tested in hemodynamically stable patients over a 2-year period. An abnormal AUS led to helical CT. When the CT showed more than 2
findings suggestive of BBMI, laparotomy was performed. In case of 1 or 2 abnormal CT findings, we performed a DPL and calculated the
ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid and divided this by the WBC/RBC ratio in
peripheral blood. A ratio of 1 or higher was considered positive for BBMI, and a laparotomy was immediately performed. Patients with a
ratio of less than 1 were managed nonoperatively.
Results: In the retrospective study, 26 (1%) of 2126 patients admitted to our trauma center for blunt trauma had a BBMI, including 15
(58%) diagnosed after a median delay of 24 hours. In the prospective study, 531 patients were admitted for blunt trauma with multiple
injuries, including 131 with abdominal trauma. Computed tomography was performed in 40 patients. There were 2 criteria or more of
BBMI in 1 patient, 0 criteria in 27 patients (with an uneventful follow-up), and 1 or 2 criteria in 12 patients who had DPL with a median
ratio of 0.82 (ranges, 0.03-9). Five patients had a ratio of 1 or higher. They underwent immediate laparotomy. In all 5 cases, BBMI was
found. The 7 patients who had a ratio of less than 1 were observed in ICU and treated for extra-abdominal injuries. No BBMI injury was
missed in these patients. The accuracy of the algorithm was 100% (95% confidence interval, 0.99-1.00).
Conclusion: The proposed algorithm (based on AUS, CT, and DPL) had a high accuracy to diagnose BBMI while requiring the
performance of DPL in only a few (2%) patients.
QUIZ QUESTIONS
QUESTION 1:
Which of the following digestive structures is most commonly affected in
blunt trauma of the gastrointestinal tract?
1. stomach
2. duodenum
3. proximal jejunum — this was the correct answer
4. ascending colon — your answer was incorrect
5. descending colon
Which of the following digestive structures is most commonly affected
in blunt trauma of the gastrointestinal tract?
1. stomach
2. duodenum
3. proximal jejunum
4. ascending colon
5. descending colon
 Explanation
 The proximal jejunum (near the ligament of Treitz) is most commonly affected
trauma of the gastrointestinal tract, followed by the duodenum and ascending
valve region. Stomach and descending colon are less commonly involved.
QUESTION 2:
In an individual patient, which of the following mechanisms is most
likely to result in a bowel injury?
1. blunt trauma assault
2. fall
3. motor vehicle accident — your answer was incorrect
4. sports-related trauma
5. stabbing — this was the correct answer
In an individual patient, which of the following mechanisms is most
likely to result in a bowel injury?
1. blunt trauma assault
2. fall
3. motor vehicle accident
4. sports-related trauma
5. stabbing
 Explanation
 Bowel and mesenteric injuries are more likely to occur after penetrating trauma with
gunshot wounds (~75%) and stabbings (~20%) being the leading causes. The bowel
and mesentery are injured in ~2.5% of blunt trauma cases with motor vehicle
collisions being most common cause of blunt trauma followed by falls, assaults and
sports related trauma.
QUESTION 3:
What is the most common site of traumatic bowel injury?
1. stomach
2. duodenum
3. jejunum
4. ileum
5. colon
6. rectum
What is the most common site of traumatic bowel injury?
1. stomach
2. duodenum
3. jejunum
4. ileum
5. colon
6. Rectum
 Explanation
 From most to least common sites of bowel injury:
• jejunum (near ligament of Trietz/D-J flexure)
• ileum (near ileocecal valve)
• colon (cecum, transverse colon, sigmoid colon)
• rectum
• duodenum (D2 and D3 segments)
• stomach (greater curvature)
 Bowel and mesenteric injuries may be significant and require
immediate surgery or may be non-significant and permit nonsurgical
treatment. Early recognition of intestinal injuries from blunt abdominal
trauma is difficult only by clinical assessment. Intestinal perforations are
often found accompanying other severe intra-peritoneal injuries which
probably, are the determining factors in morbidity and mortality hence
the main emphasis lying on early detection of the injuries and reducing
the time from admission to the surgery thus playing a role in the
reduction of mortality and morbidity associated with intestinal injuries
abdominal trauma.
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Injuries to bowel and mesentery. Lecture pptx

  • 1. Mr. Shashi Prakash M. Sc. Nursing II Year
  • 2.  The bowel and the mesentery represent the structures most frequently involved in blunt abdominal trauma (BAT) after the liver and the spleen.  The relative infrequency of such injuries, explains the high rates of delayed and missed diagnoses.  Delayed diagnosis of bowel and mesenteric injuries, by as few as 8 h, may result in severe complications and high mortality rates, mainly related to bleeding, peritonitis, and sepsis.  In the current era of non-operative management of patients with BAT, the radiologist is not only asked to detect signs of intestinal and mesenteric traumatic injuries but also to formulate a clinical degree of severity of such lesions, identifying those requiring an immediate operative treatment (angiography or surgery), substantially represented by intestinal perforation, active bleeding, and vascular avulsion of the mesentery, resulting in septic, hemorrhagic, and ischemic complications
  • 3.  Small bowel injuries  Most common site of hollow viscus injury  Majority in penetrating trauma, up to 60%  Less than 1% of all trauma admissions  1.1% of admissions after blunt injury  2.9% patients undergoing abdominal workup (CT, abdominal ultrasound, diagnostic peritoneal lavage, exploratory laparotomy)  0.3% of all blunt trauma patients have perforated small bowel injury  Duodenal injuries  6.7% in penetrating abdominal cases, 0.1% blunt abdominal trauma  12% of blunt hollow viscus injuries
  • 4. Colon: usually due to penetrating trauma Second most commonly injured organ in penetrating abdominal injury 20% patients with penetrating abdominal trauma and 7% patients with pelvic gunshot wounds have rectal injury 0.3%-5% among blunt trauma
  • 6.
  • 7.
  • 8.
  • 9.  Most common: small bowel (70 %).  In particular, proximal jejunum near the ligament of Treitz, distal ileum near the ileo-cecal valve, intestinal segments close to adhesions are mostly exposed to damage being close to points of anatomical or constituted fixity, where mobile and fixed portions of the gut are contiguous and, therefore, susceptible to shearing force.  Colon injury from BAT is uncommon (20 %), being diagnosed in about 0.5 % of all major blunt traumas and in 10.6 % of patients undergoing laparotomy.  Most of colonic injuries are “partial-thickness” (only 3 % of patients undergoing laparotomy have “full-thickness” colonic tears).  The ascending and descending colon, fixed, partially retroperitoneal segments, are generally exposed to more severe injuries compared to the transverse and the sigmoid colon, wrapped in their own meso and, therefore, characterized by a certain mobility. The duodenum represents the structure less frequently involved in blunt intestinal and/or mesenteric trauma .
  • 10. Road traffic accidents (RTA, 70–85 %), aggressions and falls from heights. With regard to RTA, an increase in intestinal and/or mesenteric lesions has been registered after the introduction of seat belts, which compress the intestinal loops at impact creating a “closed” hollow viscus and cause a sudden increase of the intraluminal pressure resulting in bursting injuries. The presence of a “seat belt mark” sign is not surprisingly considered a reliable predictor of bowel injury. • The incidence of BIMT is significantly higher in childhood, (impact of the bicycle’s handlebar against the abdominal wall) Pathogenic mechanisms at the basis of BIMT are substantially three: acting, isolated or combined: –
  • 11. • Abdominal pain (often severe and diffuse) • Abdominal distention • Severe abdominal cramping • Bloating, Nausea and vomiting • Rigidity, Guarding • Lack of bowel sounds, paralytic ileus • Rectal bleeding • Fever (usually not immediately) • Chills • Fatigue • Rebound tenderness.
  • 12. Objective data Clear clinical signs of peritonitis have late onset (may not appear for hours), especially in the case of traumatic perforation of the small intestine, whose content is characterized by neutral pH, low bacterial charge, and weak enzymatic activity Symptoms can be hidden or attenuated by concomitant injuries, as in the case of major trauma or neurological impairment due to involvement of the head or spinal cord, or by medications which can mask pain and guarding The attention for suspicious signs from the gastro-intestinal tract can be reduced by coexisting, distracting lesions, such as a femur fracture Clinical assessment alone as the indication for laparotomy to treat bowel or mesenteric injuries is associated with a negative laparotomy rate that may be as high as 40 %
  • 13.  Inspection; Penetrating and Blunt Trauma  Percussion  Auscultation  Blood tests  Plain X-ray  Ultrasound (FAST)  CT Scan  Diagnostic Laparoscopy  Diagnostic Peritoneal Lavage
  • 14.
  • 15. Traumatic Bowel Injuries Major “full-thickness” tear of the intestinal wall resulting in the spillage of enteric contents into the abdominal cavity Minor incomplete tears of the intestinal wall, intramural hematomas, and parietal contusions; are now widely managed non-operatively
  • 16. SPECIFIC  Interruption of the bowel wall  Extraluminal air/contrast  Extraluminal spillage of enteric contents  Intramural hematoma  Intramural air  Bowel wall defect NON SPECIFIC  Extraluminal air collection (intraperitoneal, mesenteric or retroperitoneal)  Intraperitoneal fluid  Bowel wall thickening  Abnormal bowel wall enhancement
  • 17. ABDOMINAL STAB WOUNDS. Gross pathology Fresh stab wound of the colonic wall
  • 18. FRESH STAB WOUND OF THE TRANSVERSE COLON (GROSS PATHOLOGY) CASE CONTRIBUTED BY DR HENRY KNIPE Presentation Abdominal stab wounds. Patient Data Age: 42 years Gender: Female https://radiopaedia.org/cases/29961/play?lang=us
  • 19. TRAUMATIC BOWEL PERFORATION AT THE DUODENOJEJUNAL FLEXURE CASE CONTRIBUTED BY DR ROBERT G Presentation Left upper abdominal pain after she fell off her bicycle and was hit in the abdomen by the handlebar Patient Data Age: 25 years Gender: Female Patient Data  Radiology Quiz 19450 | Radiopaedia.org
  • 20. TRAUMATIC SMALL BOWEL PERFORATION: HANDLEBAR INJURY CASE CONTRIBUTED BY DR IAN BICKLE Presentation Fall from bicycle. Body hit the handlebars. Abdominal pain. No distension. Patient Data  Age: 35 years  Gender: Male Patient Data  https://radiopaedia.org/cases/58713/play?lang=us
  • 21. TRAUMATIC SMALL BOWEL PERFORATION: HANDLEBAR INJURY CASE CONTRIBUTED BY DR IAN BICKLE Presentation Fall from bicycle. Body hit the handlebars. Abdominal pain. No distension. Patient Data Age: 35 years Gender: Male Patient Data  https://radiopaedia.org/cases/58713/play?lang=us
  • 22. TRAUMATIC BOWEL INJURY CASE CONTRIBUTED BY RMH CORE CONDITIONS Presentation Motor vehicle collision. Driver. Patient Data Age: 90 years Gender: Male https://radiopaedia.org/cases/26328/play?lang=us
  • 23. TRAUMATIC SMALL BOWEL PERFORATION: HANDLEBAR INJURY CASE CONTRIBUTED BY DR IAN BICKLE Presentation Fall from bicycle. Body hit the handlebars. Abdominal pain. No distension. Patient Data Age: 35 years Gender: Male Patient Data  https://radiopaedia.org/cases/58713/play?lang=us
  • 24.
  • 26. Bowel perforation at the ligament of Treitz in a 55-year- old woman after a motor vehicle accident. (B) Axial computed tomography image, showing a suspicious defect (white arrow) with focal fluid and extraluminal air (arrowhead) adjacent to the duodenojejunal junction. There also is free pneumoperitoneum (black arrows). There is a posttraumatic jejunojejunal intussusception (dashed arrow). 1. Extraluminal Air 2. Extraluminal Contrast
  • 27. 3. Bowel-Wall Defect  Splenic lacerations and ileal perforation in a 66-year-old woman involved in a motor vehicle injury. (A) Axial contrast-enhanced computed tomography (CT), revealing multiple large splenic lacerations (arrows) with hemoperitoneum (arrowheads)
  • 28.  (B, C) Caudal CT sections, revealing an ileal loop perforation (arrow in B) with free extraluminal air (arrowhead in C). There is a large hemoperitoneum 4. Extraluminal Air
  • 29.  (B) Caudal CT section, revealing a complete transection at the junction of the D2 and D3 segments of the duodenum (white arrows) with associated duodenal-wall thickening and hematoma (black arrow). There also is a traumatic right lateral abdominal wall hernia through the diaphragmatic insertion with the hepatic flexure seen in the hernial sac (arrowhead). Bowel-Wall Thickening
  • 30.  A 31-year-old woman involved in a motor vehicle accident, with active arterial mesenteric bleed. (A) Axial-contrast computed tomography, revealing extravasation of contrast (arrow) 1. Injury to the Mesenteric Vasculature (Appear as beading or termination of vessels. Beading appears as vessel irregularity, whereas termination is seen as abrupt cutoff of the mesenteric artery or vein) 2. Mesenteric Extravasation
  • 31. Traumatic Mesenteric Injuries Major active blood extravasation, avulsion of the meso resulting in intestinal ischemia and full-thickness tear of the meso, require urgent operative treatment. Minor partial lacerations of the meso, focal mesenteric contusions, and the stable mesenteric hematomas
  • 32. SPECIFIC Avulsion of the meso with intestinal ischemia Active blood extravasation Mesenteric hematoma NON-SPECIFIC Mesenteric “infiltration” Free abdominal fluid
  • 33.  Little can be done for the patients with abdominal injuries in the field.  General features of stabilization and evaluation include ensuring an adequately functioning airway, inserting i/v lines in upper extremity, and beginning of fluid resuscitation.  For penetrating wound sterile dressing should be applied.  Any foreign body embedded in the trunk should not be removed, as major bleeding may follow.  Evisceration is best left undisturbed, except to apply a sterile dressing and protect the patient from further injury.  Proper position  Early rapid transport
  • 34.  Diagnosis: requires history, examination & investigation  History  Primary goal is to identify that injury exists, not necessary making an accurate Dx  History from prehospital care, or transferring team; vital signs, physical assessment, prehospital course, and response to therapy should be obtained.  Mechanism of injury is important factor in making high index of suspicion, so detailed history is helpful if available.
  • 35.  In case of blunt trauma, determine  The types of vehicles involved  The speed they were traveling  Collision patterns  Use of seatbelts  Air bag deployment  The patient’s position in the vehicle  In case of penetrating trauma by gunshot, determine  Type of weapon used  Number of shots  Distance from victim
  • 36.  Back pain associated with compression fracture of the upper limbs or spinal region carries an associated 20% chance of renal injury.  Associated symptoms  Pain, vomiting, hematuria, hematochezia, dyspnea, respiratory distress.  Thus in combination with the aspects of physical diagnosis and adjuncts to physical diagnosis as discussed below, fracture on the lower left chest, there is a 20% chance of associated splenic injury, and with rib fracture on the right there is 10% chance of liver injury.
  • 37.  The ABCDE should be initiated.  Patent air way, if necessary ETT with assisted ventilation should begin particularly in comatose patients.  Upper extremity, large bore I.V cannulas  I.V fluids with RL should begin immediately  Next, perform a rapid neurologic examination and assess head to toe  to identify obvious injuries and signs of  prolonged exposure to heat or cold.  If your patient sustained blunt trauma, as in a motor vehicle crash (MVC), keep his neck and spine immobilized until X-rays rule out a spinal injury.
  • 38.  Vitals monitoring  Blood sampling, for hematologic, biochemical, serologic investigations should be carried out.  ABGs, and are repeated to assess ventilatory status and acidosis.  Control the patient’s pain without sedating him, so you can continue to assess his injuries and ask him questions. Generally, I.V. analgesics such as morphine can adequately manage pain without sedation.  An early rapid assessment of the abdomen is performed.  Insert a gastric tube to decompress the patient’s stomach, prevent aspiration, and minimize leakage of gastric contents and contamination of the abdominal cavity. This also gives you access to gastric contents to test for blood, the presence of blood becomes indication for operation in penetrating trauma.  Administer tetanus prophylaxis and antibiotics as ordered.
  • 39.  Inspection, palpation, auscultation, percussion,  Inspection: abrasions, contusions, lacerations, deformity, entrance and exit wounds to determine path of injury.  Grey-Turner sign  Cullen sign  Kehr sign  Left shoulder pain while supine; caused by diaphragmatic  Irritation (splenic injury, free air, intra-abdominal bleeding)  Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding  Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum.  Auscultation: bowel sounds may b decreased(late finding).
  • 40. Bluish discoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.
  • 41. Bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage
  • 42.
  • 43.
  • 44.
  • 45.
  • 46. Abdominal-Wall Hernia Diaphragmatic Hernia Small-Bowel Intussusceptions Posttraumatic Appendicitis Abdominal Compartment Syndrome
  • 47.  Trauma patients with severe intra- abdominal injuries, presenting in profound shock and requiring large amounts of intravenous fluids are those most susceptible to the development of sudden increase in intra abdominal pressure.  This syndrome is characterized by abdominal distension, oliguria, hypoxia, and increased pulmonary pressure.  The diagnosis is confirmed by the measuring the intra abdominal pressure directly or the intravesical pressure.
  • 48.  Renal failure  Decreased urine output  Respiratory failure  Decrease compliance, increased pulmonary edema / airway pressure  Cardiac failure  Decreased cardiac output (decreased preload / increased after load)  Visceral failure  Dec blood flow to liver, bowel (bacterial translocation)  Neurologic complications  Increased intracranial pressure  Abdominal wall “failure”  Dehiscence, hernia formation
  • 49.  Surgical abdominal decompression  Nonsurgical: paracentesis, NGT, sedation  Staged approach to abdominal repair  Temporary abdominal closure
  • 50.  Ineffective breathing pattern related to injury to muscles as evidenced by breathing pattern.  Acute Pain related to trauma as evidenced by verbalization and facial expressions.  Imbalanced nutrition less than body requirement related to injury as evidenced by intake and output chart.  Impaired skin integrity related to wound as evidenced by inspection and observation.  Activity intolerance related to imbalanced nutrition and pain.  Increased risk of hypovolemia and shock related to abdominal trauma and internal bleeding.  Increased risk of sepsis related to acute inflammatory process and peritonitis.  Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation.  Anxiety related to the symptoms of disease and fear of death.
  • 51.  Promote adequate respiratory and cardiovascular function.  Provide measures for prevention of the shock and sepsis.  Prevent avoidable injury and complications.  If surgical intervention prescribed, prevent postoperative complications.  Relief or diminish symptoms.  Decreased anxiety with increased knowledge of disease, it treatment, and follow-up.
  • 52.
  • 53.
  • 54. Abstract Purpose: Currently, nonoperative management is the procedure of choice for solid organ injury in patients with a blunt abdominal trauma. Missed blunt bowel and mesenteric injuries (BBMIs) are possible because diagnosis is difficult. The aim of our study was to test a new algorithm for BBMI diagnosis using abdominal ultrasonography (AUS), computed tomography (CT), and diagnostic peritoneal lavage (DPL). Methods: We reviewed cases of blunt abdominal injuries over a 10-year period, then we designed an algorithm that was prospectively tested in hemodynamically stable patients over a 2-year period. An abnormal AUS led to helical CT. When the CT showed more than 2 findings suggestive of BBMI, laparotomy was performed. In case of 1 or 2 abnormal CT findings, we performed a DPL and calculated the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid and divided this by the WBC/RBC ratio in peripheral blood. A ratio of 1 or higher was considered positive for BBMI, and a laparotomy was immediately performed. Patients with a ratio of less than 1 were managed nonoperatively. Results: In the retrospective study, 26 (1%) of 2126 patients admitted to our trauma center for blunt trauma had a BBMI, including 15 (58%) diagnosed after a median delay of 24 hours. In the prospective study, 531 patients were admitted for blunt trauma with multiple injuries, including 131 with abdominal trauma. Computed tomography was performed in 40 patients. There were 2 criteria or more of BBMI in 1 patient, 0 criteria in 27 patients (with an uneventful follow-up), and 1 or 2 criteria in 12 patients who had DPL with a median ratio of 0.82 (ranges, 0.03-9). Five patients had a ratio of 1 or higher. They underwent immediate laparotomy. In all 5 cases, BBMI was found. The 7 patients who had a ratio of less than 1 were observed in ICU and treated for extra-abdominal injuries. No BBMI injury was missed in these patients. The accuracy of the algorithm was 100% (95% confidence interval, 0.99-1.00). Conclusion: The proposed algorithm (based on AUS, CT, and DPL) had a high accuracy to diagnose BBMI while requiring the performance of DPL in only a few (2%) patients.
  • 55. Abstract Purpose: Currently, nonoperative management is the procedure of choice for solid organ injury in patients with a blunt abdominal trauma. Missed blunt bowel and mesenteric injuries (BBMIs) are possible because diagnosis is difficult. The aim of our study was to test a new algorithm for BBMI diagnosis using abdominal ultrasonography (AUS), computed tomography (CT), and diagnostic peritoneal lavage (DPL). Methods: We reviewed cases of blunt abdominal injuries over a 10-year period, then we designed an algorithm that was prospectively tested in hemodynamically stable patients over a 2-year period. An abnormal AUS led to helical CT. When the CT showed more than 2 findings suggestive of BBMI, laparotomy was performed. In case of 1 or 2 abnormal CT findings, we performed a DPL and calculated the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid and divided this by the WBC/RBC ratio in peripheral blood. A ratio of 1 or higher was considered positive for BBMI, and a laparotomy was immediately performed. Patients with a ratio of less than 1 were managed nonoperatively. Results: In the retrospective study, 26 (1%) of 2126 patients admitted to our trauma center for blunt trauma had a BBMI, including 15 (58%) diagnosed after a median delay of 24 hours. In the prospective study, 531 patients were admitted for blunt trauma with multiple injuries, including 131 with abdominal trauma. Computed tomography was performed in 40 patients. There were 2 criteria or more of BBMI in 1 patient, 0 criteria in 27 patients (with an uneventful follow-up), and 1 or 2 criteria in 12 patients who had DPL with a median ratio of 0.82 (ranges, 0.03-9). Five patients had a ratio of 1 or higher. They underwent immediate laparotomy. In all 5 cases, BBMI was found. The 7 patients who had a ratio of less than 1 were observed in ICU and treated for extra-abdominal injuries. No BBMI injury was missed in these patients. The accuracy of the algorithm was 100% (95% confidence interval, 0.99-1.00). Conclusion: The proposed algorithm (based on AUS, CT, and DPL) had a high accuracy to diagnose BBMI while requiring the performance of DPL in only a few (2%) patients.
  • 56.
  • 57.
  • 59. QUESTION 1: Which of the following digestive structures is most commonly affected in blunt trauma of the gastrointestinal tract? 1. stomach 2. duodenum 3. proximal jejunum — this was the correct answer 4. ascending colon — your answer was incorrect 5. descending colon
  • 60. Which of the following digestive structures is most commonly affected in blunt trauma of the gastrointestinal tract? 1. stomach 2. duodenum 3. proximal jejunum 4. ascending colon 5. descending colon  Explanation  The proximal jejunum (near the ligament of Treitz) is most commonly affected trauma of the gastrointestinal tract, followed by the duodenum and ascending valve region. Stomach and descending colon are less commonly involved.
  • 61. QUESTION 2: In an individual patient, which of the following mechanisms is most likely to result in a bowel injury? 1. blunt trauma assault 2. fall 3. motor vehicle accident — your answer was incorrect 4. sports-related trauma 5. stabbing — this was the correct answer
  • 62. In an individual patient, which of the following mechanisms is most likely to result in a bowel injury? 1. blunt trauma assault 2. fall 3. motor vehicle accident 4. sports-related trauma 5. stabbing  Explanation  Bowel and mesenteric injuries are more likely to occur after penetrating trauma with gunshot wounds (~75%) and stabbings (~20%) being the leading causes. The bowel and mesentery are injured in ~2.5% of blunt trauma cases with motor vehicle collisions being most common cause of blunt trauma followed by falls, assaults and sports related trauma.
  • 63. QUESTION 3: What is the most common site of traumatic bowel injury? 1. stomach 2. duodenum 3. jejunum 4. ileum 5. colon 6. rectum
  • 64. What is the most common site of traumatic bowel injury? 1. stomach 2. duodenum 3. jejunum 4. ileum 5. colon 6. Rectum  Explanation  From most to least common sites of bowel injury: • jejunum (near ligament of Trietz/D-J flexure) • ileum (near ileocecal valve) • colon (cecum, transverse colon, sigmoid colon) • rectum • duodenum (D2 and D3 segments) • stomach (greater curvature)
  • 65.
  • 66.  Bowel and mesenteric injuries may be significant and require immediate surgery or may be non-significant and permit nonsurgical treatment. Early recognition of intestinal injuries from blunt abdominal trauma is difficult only by clinical assessment. Intestinal perforations are often found accompanying other severe intra-peritoneal injuries which probably, are the determining factors in morbidity and mortality hence the main emphasis lying on early detection of the injuries and reducing the time from admission to the surgery thus playing a role in the reduction of mortality and morbidity associated with intestinal injuries abdominal trauma.