Bowel trauma (case studies)
We can now reinforce the concepts of CT evaluation for bowel injury lesson by reviewing a series of real CT cases.
Case 1: Motor vehicle collision
A 22 year old female restrained driver is transferred to emergency by ambulance following a high-speed motor vehicle collision. An abdominal CT scan is performed.
Review of SOLID ORGANS
Starting in the upper abdomen, there is no solid organ injury nor are there any surrounding blood products
Review of BOWEL
As we scan the bowel for signs of injury, there is blood in the right abdominal cavity surrounding the ascending colon. This is associated with subtle wall thickening and decreased enhancement. The blood tracks along the mesentery.
We see wall thickening of the bowel and blood products tracking along the mesentery on the coronal images
TREATMENT
These findings are highly concerning for colonic and mesenteric injury, and the patient was taken to the operating room for exploration where they confirmed a serosal tear and mesenteric injury.
This resulted in the need for a right hemicolectomy. Thus, even a subtle injury like this is crucial to detect as it can result in the need for a major surgery.
Case 2: Knife wound
A 20 year old male is rushed to the ER following a knife wound to the left lateral flank. An abdominal CT scan is performed.
Immediate review
The first thing we notice is free air in the upper abdomen, indicating that perforation has occurred.
Review of SOFT TISSUES
Now let’s try and find the source, starting with identifying the entry wound from the stab injury. In the left lateral flank, there is a subtle soft tissue defect indicating the site of stabbing.
Review of BOWEL
The stabbing injury is directed toward the descending colon, which contains oral contrast. The next image shows that this contrast is leaking out of defects in the colonic wall with an associated haematoma, indicating that the knife has injured the wall.
Those same findings are also visible in the coronal views below, where there is a large defect of the colonic wall with leakage of contrast into the paracolic gutter.
TREATMENT
This injury will require urgent surgical attention.
Remember that even the most subtle signs of potential bowel injury should be communicated early so the surgical team can consider exploration or close clinical follow-up with serial examinations.
Case 3: Skydiving injury
This case features a patient who presented after a skydiving injury with abdominal pain.
General review
Starting our review in the upper abdomen, we notice a lot of dark space in front of the liver. This is free intraperitoneal air. There is also some fluid and dots of air in the left abdomen, likely due to bowel perforation.
Flipping to lung windows, we can see this free intraperitoneal air more clearly, and how the air outlines the falciform ligament, connecting the liver to the anterior body wall.
Remember, free air indicates that there has been perforation of the bowel, so let’s take a closer look on soft tissue windows to see if we can locate the site of injury. There are smaller pockets or dots of air surrounding mildly thickened small bowel loops in the left upper quadrant, particularly surrounding the jejenum.
The proximal jejunum is tethered to the retroperitoneum at the ligament of Treitz. A deceleration injury can tear the jejunum near this fixation point—a likely mechanism of injury in this skydiving accident.
Treatment
This patient was taken to the operating room where jejunal injury was confirmed and repaired. The fluid and small pockets of air helped direct the surgical team’s attention directly to the location of the injury.
This is an edited excerpt from the Medmastery course Abdomen CT: Trauma by Michael P. Hartung, MD. Acknowledgement and attribution to Medmastery for providing course transcripts
- Hartung MP. Abdominal CT: Common Pathologies. Medmastery
- Hartung MP. Abdominal CT: Essentials. Medmastery
- Hartung MP. Abdomen CT: Trauma. Medmastery
References
- Top 100 CT scan quiz. LITFL
Radiology Library: Abdominal Trauma. Solid organ injury
- Hartung MP. Abdominal Trauma: bowel and mesenteric trauma
- Hartung MP. Bowel trauma [case studies]
- Hartung MP. Mesenteric injury and bowel shock [case studies]
- Hartung MP. Diaphragmatic injuries
Abdominal CT interpretation
Assistant Professor of Abdominal Imaging and Intervention at the University of Wisconsin Madison School of Medicine and Public Health. Interests include resident and medical student education, incorporating the latest technology for teaching radiology. I am also active as a volunteer teleradiologist for hospitals in Peru and Kenya. | Medmastery | Radiopaedia | Website | Twitter | LinkedIn | Scopus
MBChB (hons), BMedSci - University of Edinburgh. Living the good life in emergency medicine down under. Interested in medical imaging and physiology. Love hiking, cycling and the great outdoors.