AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Background

The diagnosis and management of bowel trauma has evolved over many centuries.

Historic methods

One of the earliest descriptions of bowel trauma came from the Byzantine Empire (324-1453 CE). The historical writer Philostorgius (fifth century) described the fatal wounding of Emperor Julian the Apostate (361-363 CE) when he wrote, "a cavalryman severely wounded the emperor in the abdomen with his spear and injured the peritoneum and intestines; when the point of the weapon was pulled out, there followed an outflow of feces mixed with blood."

For centuries, bowel trauma was managed conservatively, with occasional reports of the reduction of prolapsed portions of the GI tract. This treatment had a high mortality rate, and survivors escaped death by withstanding hemorrhage and sepsis.

With the introduction of firearms at the Battle of Crecy in 1346, penetrating abdominal wounds became more severe. The first exploratory laparotomy was performed in 1834 by a French surgeon named ML Baudens. Baudens also recommended introducing a finger or small sponge through the abdominal wound to determine the presence of blood, feces, or bubbles of gas and, if present, to proceed with a laparotomy. This was the first diagnostic evaluation for bowel injury.

In the early 1900s, Nicholas Senn, a surgeon, proposed to diagnose intestinal perforation using a technique termed the Senn hydrogen gas insufflation test. This diagnostic test involved insufflating hydrogen gas into the anus of a wounded patient. A lighted taper was then placed near the entrance wound. If a small explosion accompanied by a flaring blue flame occurred, this was considered a positive finding for intestinal perforation.

A turning point in the conservative management of penetrating bowel trauma came after the assassination of President James Garfield in 1881. Although he was managed conservatively and died 3 months later of a mycotic aneurysm, his death brought the debate of abdominal exploration to academic discussion.

During WWII, soldiers presenting with penetrating wounds underwent radiographic examinations, had nasogastric tubes inserted, received penicillin, and underwent exploratory laparotomy. From WWII to the Vietnam War, mortality from penetrating gunshot wounds decreased from 42-9%.

With the introduction of radiography in the evaluation of blunt abdominal trauma, diagnostic accuracy improved. Abdominal radiographs could detect as little as 1 cm³ of free gas outside the intestinal tract. However, plain radiographs were nonspecific. Addition of conventional contrast procedures helped by identifying extravasation from perforated viscera.

Modern methods

In 1965, diagnostic peritoneal lavage (DPL) was introduced. DPL involves making a small midline incision and instilling 1 L normal saline or Ringer lactate into the peritoneum. Eluted fluid is examined for blood, particulate matter (fecal, vegetable), or bacteria.

In 1971, the use of ultrasound (US) to evaluate blunt abdominal trauma was first reported. During this period, angiography also was used to evaluate blunt abdominal trauma to detect mesenteric, retroperitoneal, or solid organ hemorrhage.

CT was invented in 1971. The use of CT to evaluate blunt abdominal trauma was first reported in 1979, when an EMI scanner was used to study blunt trauma in 4 patients. The identified injuries included lacerated spleen, hepatic hematoma, and 2 renal hematomas.

Since 1979, the resolution and scanning time of CT have improved as well as its ability to detect bowel injury. Currently, multi-row helical detector CTs are capable of scanning the abdomen in less than 30 seconds and can detect free air, free fluid, abnormal bowel wall enhancement, bowel wall thickening, and mesenteric infiltration. These advances in CT have brought the debate of conservative management of abdominal trauma full circle. Currently, many patients with blunt abdominal trauma or retroperitoneal penetrating trauma can be managed without surgery and can avoid unnecessary laparotomy.

Advances in the diagnosis and management of bowel abdominal trauma undoubtedly will proceed from advances in technology. Multidetector CT scanning using 16- and 64-slice CT has increased the speed in which trauma patients are scanned. In addition, 16- and 64-slice multidetector CT imaging allows the creation of isotropic voxels that allow reformats to be performed in sagittal and coronal planes, which can allow better localization of bowel injuries. Currently, CT is used in 3-dimensional reconstructions of the colon (CT colonography). The use of CT to reconstruct the entire alimentary tract to detect bowel trauma is not unreasonable.

Interventional radiology and techniques of minimally invasive surgery also are revolutionizing treatment of bowel trauma. Laparoscopy is being used in hemodynamically stable patients with blunt abdominal trauma to identify and repair small bowel injuries. Percutaneous management of abscesses and hematomas provides a minimally invasive, although sometimes only temporary, alternative to open exploratory laparotomy in patients who may have multiple other injuries.

Pathophysiology

Bowel injury can result from both blunt and penetrating trauma to the abdomen. Blunt trauma is the most common mechanism of injury to the bowel. Of patients with blunt abdominal trauma, 5% will have intestinal and mesenteric injury. Blunt trauma can occur from vehicular accidents, falls, and assaults. Penetrating trauma to the gut occurs more frequently in the urban setting and typically is secondary to knife or gunshot wounds.

• Blunt abdominal trauma: The physical forces involved in the mechanism of injury to the bowel in blunt abdominal trauma can be divided into 2 categories, compression forces and deceleration forces.
  • Compression forces act by increasing the intraluminal pressure in the bowel or by compressing fluid-filled bowel against solid structures (eg, duodenal compression on the spine). Compressive forces result in a spectrum of injuries that range from stretching the bowel wall to full-thickness perforation.
  • Deceleration forces cause stretching and tearing of bowel loops at points of fixation, such as the ligament of Treitz, the ileocecal valve, and the phrenocolic ligament. Deceleration injuries range from tearing the bowel wall, to shearing the mesentery, to loss of vascular supply to the segment of gut.
• Penetrating trauma: The spectrum of injury from penetrating trauma ranges from abrasion of the serosa, to full-thickness penetration of the bowel wall in 1 or multiple areas, to mesenteric and vascular injury.

Frequency

United States

In the United States, trauma is the leading cause of death in men and women younger than 40 years and is the third leading cause of death in all age groups.

International

In industrialized countries, trauma is the leading cause of death among individuals aged 1-40 years. Worldwide, 1 in 10 deaths occur from traumatic injuries. Specific statistics regarding trauma to the bowels is not available.

Mortality/Morbidity

The abdomen is the third most commonly injured body region, and 10% of trauma deaths result from abdominal injuries. Morbidity and mortality in bowel trauma occur as a result of hemorrhage of injured mesenteric vessels or peritonitis from bowel wall rupture.

Sex

Overall, males have a higher incidence of traumatic injuries than females.

Age

Traumatic injury is the leading cause of death in males and females aged 1-40 years.

Anatomy

Each anatomic region of the GI tract is associated with characteristic patterns of injury. Most full-thickness gastric injuries result from penetrating trauma. Blunt abdominal gastric trauma occurs after a full meal. The most common site of gastric rupture is the anterior wall, followed by the greater curvature, the lesser curvature, and the posterior wall.

Of duodenal injuries, 75% are secondary to penetrating trauma and 25% to blunt trauma. Blunt duodenal injury usually occurs in the second or third portion of the duodenum, where the duodenum can be compressed against the spine. Shearing injury also can occur adjacent to the ligament of Treitz. Duodenal injuries include duodenal wall hematoma, which can be managed without surgery, and duodenal wall rupture, which requires emergent surgery.

Injury often occurs near points of fixation, such as the ligament of Treitz or ileocecal valve. Rupture often occurs along the antimesenteric border.

Colonic injury can occur from both penetrating and blunt trauma. Blunt trauma frequently involves compressive injury to the transverse colon, the sigmoid colon, or the cecum.

Clinical Details

Evaluation of a patient with potential bowel trauma includes the following steps:

1. Initially, assess the patient's airway, breathing, and circulation.
2. During the secondary survey, examine the abdomen to identify swelling, bruising, scratches, and areas of skin penetration.
3. Assess bowel sounds.
4. Carefully palpate the abdomen, first in the area of least tenderness, and then extend the palpation to the perceived area of tenderness or injury.

Swelling, bruising, skin penetration, lack of bowel sounds, guarding, and direct and rebound tenderness suggest the possibility of bowel injury. Clinical signs of bowel injury (ie, abdominal tenderness, rigidity, absent bowel sounds) are present in only 31% of patients.

Preferred Examination

CT of the abdomen is the preferred diagnostic examination for the evaluation of blunt abdominal trauma in the hemodynamically stable patient with blunt abdominal trauma and in selected instances of penetrating trauma to the posterior abdomen. Unstable patients or patients with penetrating injuries to the abdomen undergo exploratory laparotomy.

Abdominal CT examination should be systematic.

• Traumatic injury to the bowel is rarely isolated.
• First, evaluate the more commonly injured organs, such as the liver and spleen, as well as the pancreas, adrenals, kidneys, blood vessels, spine, and skeletal structures.
• Evaluate traumatic injury to the bowel in the context of the mechanism and location of injury.
  • Right upper quadrant: Examine the right lung base, right hemi-diaphragm, liver, gallbladder, right colon, right adrenal, right kidney, and right abdominal small bowel loops.
  • Midline: Evaluate the base of the heart, diaphragm, pancreas, duodenum, aorta, inferior vena cava, and small bowel mesentery.
  • Left upper quadrant: Evaluate the base of the heart, base of the left lung, left hemi-diaphragm, stomach, spleen, tail of the pancreas, left adrenal, left kidney, left colon, and small bowel loops.
  • Lower abdomen and/or pelvis: Evaluate the bladder, rectosigmoid, and small bowel loops.

Each imaging modality (eg, plain abdominal radiograph, US, CT) demonstrates typical findings that suggest a diagnosis of bowel trauma. In the hemodynamically stable patient with abdominal trauma, CT is the study of choice.

Limitations of Techniques

The accuracy of CT for the evaluation of bowel injury is as high as 97.6%.

CT can be limited if DPL is performed prior to the CT. Free intraperitoneal fluid and air from the DPL observed on CT makes the evaluation for bowel injury very difficult.

Although CT can suggest bowel injury by demonstrating free intraperitoneal air, free fluid, or thickened bowel wall, in many instances it cannot reliably localize the exact location of bowel injury.

Delayed presentation of bowel injury occasionally occurs. Patients returning with continued symptoms several hours or days after a negative trauma should undergo repeat CT.

DIFFERENTIALS

Section 3 of 12  

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• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Other Problems to be Considered

Free air (also seen with pneumomediastinum, pneumothorax, recent DPL, laparotomy, barotrauma)
Free fluid (also caused by injury to other organs including liver, spleen, gallbladder, urinary bladder)
Bowel wall thickening (also seen with various enteritis or colitides including ischemic, inflammatory, pseudomembranous)
Abnormal bowel wall enhancement (also seen in hypotensive "shock bowel")

RADIOGRAPH

Section 4 of 12  

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• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
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• Intervention
• Multimedia
• References

Findings

Plain radiography findings in bowel injury include the following:

• Nonspecific findings may include small and/or large bowel dilation suggestive of ileus or obstruction secondary to peritonitis.
• Soft tissue density and/or mass effect on bowel gas loops suggest fluid collections, hematoma, or scoliosis resulting from splinting toward the side of injury.
• Loss of right psoas shadow suggests a retroperitoneal fluid collection from a duodenal injury.
• Free intraperitoneal air suggests bowel perforation.
• Upright abdominal films and left lateral decubitus films can detect as little as 1 mL or 2 mL of free intraperitoneal air under the diaphragm or over the liver edge, respectively.
• On supine abdominal radiographs, free air can be observed outlining the serosa of the bowel loops ("Rigler" or serosa sign) or the falciform ligament.
• Retroperitoneal air from duodenal or sigmoid injury can outline the diaphragmatic crura or the kidneys.
• GI studies using contrast can identify areas of extravasation from perforated bowel. GI studies also can help identify a duodenal hematoma.

Degree of Confidence

Plain radiographs are not highly specific or sensitive for evaluating bowel injury. Findings of free air, abdominal fluid, scoliosis, and psoas shadow obliteration are observed in fewer than 43% of patients with intestinal trauma. Fluid collections must be large (>800 mL) to be visible on plain radiographs.

False Positives/Negatives

Pneumoperitoneum does not always indicate bowel rupture and can be observed in patients with pneumomediastinum, pneumothorax, and in patients on mechanical ventilation.

CT SCAN

Section 5 of 12  

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• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
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• Intervention
• Multimedia
• References

Findings

Currently, CT is the modality of choice for evaluating abdominal trauma in the hemodynamically stable patient.

CT evaluation for blunt abdominal trauma can be difficult and requires strict attention to meticulous techniques.

Administer oral and intravenous contrast. Extend sections from the base of the lungs to below the symphysis pubis. View these sections in the "abdominal,lung,liver," and "bone" windows. Carefully search for associated injuries, including Chance or vertebral burst fractures, abdominal bruising, pancreatic, liver, spleen, adrenal, and kidney injury. Consider administering rectal contrast in patients with suggested penetrating injury to the rectum or retroperitoneal colon.

Multidetector CT scanning using a 16- or 64-slice CT allows for coronal and sagittal reformats. Examination of these off-axis images allows for improved detection and localization of bowel injuries.

The coronal plane is especially helpful because it provides an anatomic view and helps referring physicians/surgeons better understand the location and extend of injury.

The sagittal plane is helpful in the evaluation of the thoracic and lumbar spine and can detect associated compression fractures of the spine, which may be missed when viewed in the axial plane alone.

CT findings in bowel injury include the following (see Table below):

• Bowel injury is suggested by free intraperitoneal air, free intraperitoneal or retroperitoneal fluid, focal areas of bowel wall thickening, abnormal bowel wall enhancement, bowel wall hematoma (ie, duodenal hematoma), and intramural air.
• The most specific finding is the visualization of oral contrast extravasation and bowel wall disruption.
• A pattern of more diffuse bowel wall thickening, abnormal enhancement, and mesenteric infiltration can suggest mesenteric vascular injury resulting in ischemic bowel.
• In intestinal vascular injury, evaluate the celiac axis, superior mesenteric artery, and superior mesenteric vein. A mesenteric hematoma or a focal area of higher density clotted blood (ie, "sentinel clot") can suggest vascular injury.
• Focal contrast extravasation can indicate active hemorrhage.

CT Findings in Bowel Injury

Degree of Confidence

The accuracy of CT for evaluating bowel injury is 82%, with a sensitivity of 64% and a specificity of 97%.

False Positives/Negatives

Some findings on CT suggesting bowel injury can represent false-positive findings:

• Free intraperitoneal air in a trauma patient also can be observed in a patient with pneumomediastinum, pneumothorax, recent DPL, laparotomy, or barotrauma with no associated bowel injury.
• Free fluid in a trauma patient can originate from injury to other organs, including the liver, spleen, gallbladder, and urinary bladder, without any injury to the bowel.
• Bowel wall thickening and abnormal wall enhancement also can be observed in patients with hypotension or hypoperfusion without direct bowel injury.

MRI

Section 6 of 12  

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• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

MRI has no role in evaluating patients with suspected bowel trauma.

ULTRASOUND

Section 7 of 12  

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• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

Typically, the role of US in evaluating bowel trauma is limited to detecting free intraperitoneal fluid in trauma patients who are not sufficiently hemodynamically stable to undergo CT. However, the identified fluid cannot be further defined. Considerations include benign ascites, blood, urine, or bile and must be confirmed with CT.

Other findings of bowel injury include dilated bowel loops secondary to an ileus or obstruction. US is insensitive in detecting intraperitoneal free air.

NUCLEAR MEDICINE

Section 8 of 12  

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• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

Nuclear medicine has no role in evaluating acute bowel trauma.

ANGIOGRAPHY

Section 9 of 12  

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• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

The only role of angiography in acute bowel trauma is to identify the site of visceral bleeding.

INTERVENTION

Section 10 of 12  

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• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Vascular intervention includes embolization of bleeding mesenteric vessels.

Medical/Legal Pitfalls

• Delay in the diagnosis and management of a bowel injury can result in significant morbidity and mortality to the patient and can lead to medicolegal pitfalls.
• • Potential morbidity to the patient includes peritonitis, bowel ischemia, and death.
  • Although in a few cases initial diagnostic imaging may not show evidence of bowel trauma, close clinical follow-up in patients with the appropriate mechanism of injury is recommended. Typically, if an occult bowel injury is present that was not seen on the initial CT can, a follow-up CT can in 12, 24, and 48 hours is recommended to reassess evidence of bowel injury.

MULTIMEDIA

Section 11 of 12  

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• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Media file 1:  A 47-year-old man with blunt trauma to the abdomen. Axial CT through upper abdomen reveals 2 spots of free intraperitoneal air (arrows).
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Media type:  CT

Media file 2:  A 15-year-old boy with blunt trauma to the abdomen and a perforated stomach. Axial CT demonstrates large amount of free intraperitoneal air (green arrow). An air/fluid level with fluid is seen in the right paracolic gutter (red arrow). Extravasated oral contrast is seen in the left paracolic gutter (blue arrow) adjacent to the stomach.
	View Full Size Image
Media type:  CT

Media file 3:  Patient in a motor vehicle collision with injury to the spleen. Axial CT through the abdomen shows thickening and enhancement of bowel wall in the left lower quadrant resulting from hypotension and hypoperfusion of the bowel. No bowel injury was seen.
	View Full Size Image
Media type:  CT

Media file 4:  Picture 4. A 47-year-old man with blunt trauma to the abdomen. Axial CT through the level of the pelvis shows small bowel wall thickening and enhancement (red arrow) from blunt small bowel injury. Free intraperitoneal air visualized (blue arrow) is from a perforated sigmoid colon. Image from AJR 2000;174:1538 printed with permission from American Roentgen Ray Society.
	View Full Size Image
Media type:  CT

Media file 5:  A 19-year-old man with right-sided chest trauma. Axial CT through the upper abdomen shows a large amount of right retroperitoneal air surrounding the right kidney (arrows). Some air is seen in the right subcutaneous tissues. Retroperitoneal air dissected downwards from a right-sided chest pneumothorax.
	View Full Size Image
Media type:  CT

Media file 6:  Patient with blunt abdominal trauma with duodenal hematoma. Axial CT through the abdomen shows soft tissue density and mild stranding surrounding duodenum (arrow) consistent with a duodenal hematoma.
	View Full Size Image
Media type:  CT

Media file 7:  Female patient with blunt abdominal trauma and duodenal perforation. Focal axial CT of the right upper abdomen shows free intraperitoneal air (red arrow) and contrast extravasation (blue arrow) from the duodenum (yellow arrow).
	View Full Size Image
Media type:  CT

Media file 8:  Female patient with right-sided colon perforation. Axial CT through the abdomen shows focal gas bubbles (red arrow) and anextraluminal fluid collection (blue arrow) adjacent to the contrast-filled colon.
	View Full Size Image
Media type:  CT

Media file 9:  A 79-year-old woman after a motor vehicle collision. Axial CT through the level of the pelvis shows a focal area of small bowel wall thickening (red arrow) consistent with focal blunt small bowel injury. Fat stranding is seen in the mesentery (yellow arrow) consistent with a mesenteric hematoma.
	View Full Size Image
Media type:  CT

Media file 10:  A 24-year-old man with blunt abdominal trauma and duodenal hematoma. Upper gastrointestinal series of the region of the duodenum shows large filling defect (arrow) compressing the contrast-filled second portion of duodenum lumen. Findings are consistent with an intramural duodenal hematoma. No extravasation of contrast is observed that suggests duodenal perforation.
	View Full Size Image
Media type:  CT

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

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Article Last Updated: Sep 2, 2005