MDCT in Trauma to the GI tract - AKUTNE.CZ

Department of Diagnostic ImagingSection of General and Emergency Radiology

Naples, Italy

Department of Diagnostic ImagingSection of General and Emergency Radiology

Naples, Italy

Antonio CardarelliHOSPITAL

Antonio CardarelliHOSPITAL

MDCT in Trauma to theGI tract




Stefania RomanoStefania Romano

• 5 % of pts with abdominal blunt traumapresents bowel or mesenteric injuries

Butela,AJR 2001

• 1.3% of pts with blunt abdominal injurieshave small bowel or mesenteric injuries

Frick EJ, J Trauma 1999

• Association with parenchymal organ injuriesHanks PW, RCNA 2003

GI – Blunt Trauma

• 5 % of pts with abdominal blunt traumapresents bowel or mesenteric injuries

Butela,AJR 2001

• 1.3% of pts with blunt abdominal injurieshave small bowel or mesenteric injuries

Frick EJ, J Trauma 1999

• Association with parenchymal organ injuriesHanks PW, RCNA 2003

Three types of trauma :

• Crush injury

• Shearing forces at fixed sites of attachment

• Burst injuries from increase in endoluminalpressure Motz, 1890

Approximately 25% of pts requiring surgical treatmentfor bowel trauma have more than one bowel injuryand likely more than one mechanism

Wisner DH, 2000

GI – Blunt Trauma

Three types of trauma :

• Crush injury

• Shearing forces at fixed sites of attachment

• Burst injuries from increase in endoluminalpressure Motz, 1890

Approximately 25% of pts requiring surgical treatmentfor bowel trauma have more than one bowel injuryand likely more than one mechanism

Wisner DH, 2000

Crush injuries:

• Result from impact of a stationary object onthe anterior abdominal wall that catches aloop of bowel between it and spine or solidorgan

•The duodenum and transverse colon are athigher risk with this mechanism

Hanks PW, RCNA 2003

GI – Blunt Trauma

Crush injuries:

• Result from impact of a stationary object onthe anterior abdominal wall that catches aloop of bowel between it and spine or solidorgan

•The duodenum and transverse colon are athigher risk with this mechanism

Hanks PW, RCNA 2003

Shearing forces at fixed sites of attachment:• Acquired adhesions and normal points of bowelfixation at the ligament of Treitz and ileocecal junctionserve as anchor point in shear injury.

• Rapid deceleration allows a mobile segment to moverapidly away from fixed points causing the injury.

Hanks PW, RCNA 2003

GI – Blunt Trauma

Shearing forces at fixed sites of attachment:• Acquired adhesions and normal points of bowelfixation at the ligament of Treitz and ileocecal junctionserve as anchor point in shear injury.

• Rapid deceleration allows a mobile segment to moverapidly away from fixed points causing the injury.

Hanks PW, RCNA 2003

Burst injury from increase in endoluminalpressure:

• It occurs when impact with stationaryobjects reconfigures bowel into closed loop. Ifcompression continues, pressure can rise tothe point where bowel wall may burstresulting in full-thickening perforations

Hanks PW, RCNA 2003

GI – Blunt Trauma

Burst injury from increase in endoluminalpressure:

• It occurs when impact with stationaryobjects reconfigures bowel into closed loop. Ifcompression continues, pressure can rise tothe point where bowel wall may burstresulting in full-thickening perforations

Hanks PW, RCNA 2003

GI – Blunt Trauma

Main causes of the acute abdominal symptoms:

• Diaphragmatic trauma

• Parenchymal organs lesions

• Hollow organs injuries (small and large bowel,rectum, stomach)

• Lesions of the fixation structures (mesentery,retroperitoneal vessels)
















GI – Blunt Trauma

• Small bowel is less vulnerable intrauma because of the low fixity to theparietal structures

• Duodenal-jejunal angle and the ileo-cecal valve are fixed structures athigher risk in blunt trauma

• Small bowel is less vulnerable intrauma because of the low fixity to theparietal structures

• Duodenal-jejunal angle and the ileo-cecal valve are fixed structures athigher risk in blunt trauma

GI – Blunt Trauma

Determining factors in the large boweltraumatic lesions:Determining factors in the large boweltraumatic lesions:

• Hyper-pression (burst lesions)• Direct trauma• Large parietal hematoma complication• Mesentery laceration with infarcted

necrosis as potential complication

• Hyper-pression (burst lesions)• Direct trauma• Large parietal hematoma complication• Mesentery laceration with infarcted

necrosis as potential complication

GI – Blunt Trauma

• In absence of abdominal parenchymalorgans and/or vascular associatedinjuries, intestinal traumas – especiallyif no perforation occurred - cause avarious clinical symptomatology

• Diagnosis of a traumatic lesion to thesmall intestine can be difficult

• In absence of abdominal parenchymalorgans and/or vascular associatedinjuries, intestinal traumas – especiallyif no perforation occurred - cause avarious clinical symptomatology

• Diagnosis of a traumatic lesion to thesmall intestine can be difficult

• Despite the significant rate of bowel or mesentericinjury following blunt abdominal trauma (5%) and themarked increase in mortality (up to 65%) with delayeddiagnosis of bowel perforation, accurate physicaldiagnosis in this setting is fraught with difficulty. Theclassic triad of tenderness, rigidity and absent bowelsound occurred in only 31% of one series of pts andthe most consistent finding of tenderness is nonspecific in this setting.

• The appearance of signs and symptoms may bedelayed several hrs from the time of injury

Rizzo MJ, Radiology 1989

GI – Blunt Trauma

• Despite the significant rate of bowel or mesentericinjury following blunt abdominal trauma (5%) and themarked increase in mortality (up to 65%) with delayeddiagnosis of bowel perforation, accurate physicaldiagnosis in this setting is fraught with difficulty. Theclassic triad of tenderness, rigidity and absent bowelsound occurred in only 31% of one series of pts andthe most consistent finding of tenderness is nonspecific in this setting.

• The appearance of signs and symptoms may bedelayed several hrs from the time of injury

Rizzo MJ, Radiology 1989

GI Trauma – Surgical findings

Courtesy of Giovanni Bartone, MDEmergency Surgery, A.Cardarelli Hospital, Naples IT

Mesentery laceration

GI Trauma – Surgical findings


Small bowel perforation

GI Trauma – Surgical Findings


Small bowel transection


Small bowel contusion from blunt trauma

Courtesy of Francesco La Rocca, MDEmergency Surgery, A.Cardarelli Hospital, Naples IT


Large bowel contusion from blunt trauma



Small bowel burst lacerationCourtesy of Francesco La Rocca, MD

Emergency Surgery, A.Cardarelli Hospital, Naples IT


Double burst lesion of the small bowel fromblunt trauma



Mesentery laceration and intestinal segmentaryischemia of the ileum in a deceleration trauma


MDCT in GI Trauma

Study protocol in Emergency:

2.5mm slice thickness (0.6mm b.rec.)

No oral contrast medium

I.V. administration of c.m.+ saline flush

Dynamic, multiphasic acquisition

Post processing: multiplanar reformations atdedicated WS

Study protocol in Emergency:

2.5mm slice thickness (0.6mm b.rec.)

No oral contrast medium

I.V. administration of c.m.+ saline flush

Dynamic, multiphasic acquisition

Post processing: multiplanar reformations atdedicated WS

MDCT in GI Trauma

Endoluminal contrast mediumadministration in Emergency or not?Endoluminal contrast mediumadministration in Emergency or not?

• Multidetector row CT without oralcontrast medium is adequate fordepiction of bowel and mesentericinjuries that require surgical repair

Stuhlfaut JW, Radiology 2004

CT signs of bowel and mesenteric injuries:• Bowel wall discontinuity• Pneumoperitoneum• Focal bowel wall thickening• Mural hematoma• Pneumatosis• Mesenteric hematoma• Abnormal mural enhancement• Extravasation of c.m. from mesenteric vessels• Triangle shaped mesenteric fluid collections• Sentinel clot sign• Extravasation of oral c.m.

CT in GI Trauma

CT signs of bowel and mesenteric injuries:• Bowel wall discontinuity• Pneumoperitoneum• Focal bowel wall thickening• Mural hematoma• Pneumatosis• Mesenteric hematoma• Abnormal mural enhancement• Extravasation of c.m. from mesenteric vessels• Triangle shaped mesenteric fluid collections• Sentinel clot sign• Extravasation of oral c.m.

Stuhlfaut JW, Radiology 2004

Brody JM, Radiographics 2000

Levine CD, JCAT 1997

Hanks PW, RCNA 2003

Butela ST, AJR 2001

Imaging Findings:

• Functional disorders

• Contusion

• Mural Hematoma

• Laceration

• Active bleeding

MDCT in GI Trauma

Imaging Findings:

• Functional disorders

• Contusion

• Mural Hematoma

• Laceration

• Active bleeding

MDCT in GI TraumaAssociated functional disorders

Neurogenic answer totrauma: spastic reflexileus


Neurogenic answer totrauma: spastic reflexileus


Non-occlusiveintussusception inpatient with blunt trauma


Non-occlusiveintussusception in patientwith blunt trauma


Non-occlusiveintussusception in patient withblunt abdominal trauma

MDCT in GI Trauma

Gastric wall mucosalhematoma

Lassandro F, Eur J Rad 2007

MDCT in GI Trauma

Gastric wall hematoma

MDCT in GI Trauma

Mesocolon hematoma

MDCT in GI Trauma

Mesocolon hematoma

MDCT in GI Trauma

Mesocolon hematomaMesocolon hematoma

bleeding

MDCT in GI Trauma

Mesentery hematoma

MDCT in GI Trauma

Mesentery trauma

MDCT in GI Trauma

Mesentery desinserctionand laceration with activebleeding

MDCT in GI Trauma

1- Patient with blunttrauma, first CTexamination

MDCT in GI Trauma

2- Patient with blunt trauma,CT examination 1-day-later:ileal perforation from blunttrauma

MDCT in GI Trauma

1- Patient with blunttrauma, first CTexamination

MDCT in GI Trauma

2- CT examination 2 dayslater: jejunal perforation

MDCT in GI Trauma

Lassandro F, Eur J Rad 2007Lesion of serosal surfaceof the stomach

MDCT in GI Trauma

Cecal burst fromblunt trauma

MDCT in GI Trauma

Multiple bowel perforations from blunt trauma

MDCT in GI Trauma

Gastric fundus burst lesion Lassandro F, Eur J Rad 2007

MDCT in GI Trauma

Multiple entericperforationsfrom blunttrauma

MDCT in GI Trauma

Cecal rupture frommajor pelvic trauma

MDCT in GI Trauma

Cecal burst withdelayed duodenalhematoma

MDCT in GI Trauma

Active Bleeding fromJejunal blunt traumaticlesion

MDCT in GI Trauma

Gatroentericlesion fromblunt trauma,with GI andsplenicinfarction

Conclusions 1/2Conclusions 1/2

MDCT can be considered as aneffective imaging method todiagnose traumatic lesions to theGI tract and mesentery, but…




Conclusions 2/2Conclusions 2/2

• A correct timing // acquisition parametersof the exam is required

• Report the appearance of the bowel, beingmore precise regarding the presence ofparietal swelling, enhacement, freeperitoneal or retroperitonal air, activebleeding

• Share any doubt or concern in diagnosiswith the referring surgeon

• A correct timing // acquisition parametersof the exam is required

• Report the appearance of the bowel, beingmore precise regarding the presence ofparietal swelling, enhacement, freeperitoneal or retroperitonal air, activebleeding

• Share any doubt or concern in diagnosiswith the referring surgeon

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MDCT in Trauma to the GI tract - AKUTNE.CZ