Imaging of Bowel Trauma May 28 – 30, 2015, Montréal, Québec
Disclosure Statement: No Conflict of Interest . I have no conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships). May 28 – 30, 2015, Montréal, Québec
CT of Bowel and Mesenteric Injury Dr. Paul Hamilton, University of Toronto Canadian Association of Radiologists, May 28, 2015 Sunnybrook Hospital Regional Trauma Centre 3
Bowel and Mesenteric injury 1- 5% blunt trauma Surgical intervention +++ Clinical exam limited Interpretation difficult
Bowel and Mesenteric Injury …. Evaluation with CT Free fluid (96%) Free air (32%) Mesenteric infiltration (86%) Bowel wall thickening (61%) Rizzo et al. Radiology 1989
68 patients laparotomy proven blunt bowel and mesenteric injuries. Detection of significant bowel and mesenteric injuries in blunt abdominal trauma with 64-slice computed tomography Petrosoniak et al: Journal of Trauma and Acute Care Surgery: April 2013 68 patients laparotomy proven blunt bowel and mesenteric injuries. all had free fluid. 4 cases minimal ff without additional findings. Conclusions: No FF makes bowel/mesenteric injury unlikely Even minimal ff remains relevant.
Bowel and Mesenteric Injury …. Evaluation with CT Free fluid (96%) Free air (32%) Mesenteric infiltration (86%) Bowel wall thickening (61%) Rizzo et al. Radiology 1989 Oral contrast
Pseudo-pneumoperitoneum
69 female, MVC Pneumoperitoneum from chest, negative laparotomy
22 year old man, GSW left flank
25 year old man, stab wound Laparoscopy: no bowel injury
39 man, ATV accident, free air Intraperitoneal bladder rupture 12
Jejunal perforation 66 year old woman, MVC
Bowel and Mesenteric Injury …. Evaluation with CT Free fluid (96%) Free air (32%) Mesenteric infiltration (86%) Bowel wall thickening (61%) Rizzo et al. Radiology 1989
My Trauma Checklist 1. free air 2. diaphragm 3. mesenteric hematoma/fluid 4. extravasation 5. differential bowel wall enhancement (You can make you own list)
My Trauma Checklist Why these? 1. free air – (bowel perforation/surgery) 2. diaphragm – (surgical repair) 3. mesenteric hematoma/fluid – (bowel/mesenteric injury/surgery) 4. extravasation – (intervention) 5. dif. bowel wall enhancement - (surgery) 16
37 woman, office injury 17
SB mesenteric hematoma, non-therapeutic laparotomy 29 year old man, MVC
Bowel and Mesenteric Injury …. Evaluation with CT Free fluid Free air Mesenteric infiltration Bowel wall thickening Mesenteric contrast extravasation
44 year old man, work accident, pinned by truck at loading dock Differential bowel wall enhancement
Bowel and Mesenteric Injury …. Evaluation with CT Free fluid Free air Mesenteric infiltration Bowel wall thickening Mesenteric contrast extravasation Differential BW enhancement
Differential bowel wall enhancement
64 woman, MVC Sigmoid colon discontinuity 23
Bowel and Mesenteric Injury …. Evaluation with CT Free fluid Free air Mesenteric infiltration Bowel wall thickening Mesenteric vascular extravasation Differential enhancement Bowel wall discontinuity
34 year old cyclist hit by car Shock bowel Non-therapeutic laparotomy
Hypovolemic shock complex Ryan et al, Clinical Radiology, May, 2005 Bowel thickening, dilatation, hyperenhancement Small vessels (IVC, Aorta) Retroperitoneal, mesenteric edema Abnormal organ perfusion
Recommendations for CT bowel trauma free fluid use a checklist be aware of pitfalls