CT Findings
of Mesenteric
Injury
After
Blunt Trauma:
Implications
for
Surgical Intervention
Mike F. Dowe1
K. Shanmuganathan1
Stuart E. Mirvis1
R. Clayton Steiner2
Carnell Cooper2
OBJECTIVE.
mesenteric
assess
The purposes of this study were to determine
injury.
to compare
the potential
ofCT
MATERIALS
4-month
from
a radiology
bowel
before
and
and
two
of
(89%)
had
CT
be falsely
negative
discrepancies
of the surgical
Patients
mesenteric
with
observations.
injury
CT
results.
physical
Medical
findings
in two
findings
patients
surgical
results.
criteria
the
confirmed.
and
of
the study
Among
injury
other
and
meeting
conservatively.
of mesenteric
records
27
falsely
of lull-thickness
perfbrmed
reviewed
all
study
both
who
in one
were
laparotomy.
had
surgery.
showed
other
with
patients
underwent
findings
positive
identified
lavage
patients
Surgical
were
CT
patient.
24
scans
to
No major
were found between
retrospective
CT review done with and without
knowledge
findings.
Two CT findings
unique
to patients
whose
injuries.
in the judgment
of the surgical
and bowel
registry.
of 29 patients
managed
findings
a
trauma
admission
were
to
of
surgical
of
patients
with mesenteric
injury require
laparotorny.
Blunt trauma patients
admitted
to our ltcility
during
diagnosis
with
of CT findings
and
surgical
surgical
Twenty-seven
others
or
the spectrum
injury
with mesenteric
injury or diagnostic
peritoneal
CT scans of all patients
were retrospectively
knowledge
to ascertain
which
a CT
database
RESULTS.
and
with
injury
associated
CT were excluded.
reviewed
of mesenteric
METHODS.
period
without
findings
to predict
AND
5-year
CT
team,
required
surgical
wall
thickening
associated
relate well with
the type
and clinical
repair
with
were
active
mesenteric
significance
extravasation
findings.
ofthe
of IV contrast
Physical
mesenteric
findings
material
did not cor-
injury.
CONCLUSION.
The CT finding of mesenteric bleeding or bowel wall thickening
associated with mesenteric
hematoma
or infiltration
in the blunt trauma
patient
indicates
a high
likelihood
of a mesenteric
or bowel
injury
requiring
surgery.
The finding
of fical
mesenteric
or infiltration
without
adjacent
bowel wall thickening
is nonspecific
in mesenteric
or bowel lesions that require
surgery
and those that do not.
hematoma
both
I
njury to
relatively
significant
mortality
Early
Received
May 22, 1996; accepted
after
revision
July 18,
1996.
Maryland
21201.
of Diagnostic
Medical
Address
Radiology,
to K. Shanmuganathan.
Center, University
Center, Baltimore,
MD 21201.
AJR 1997;168:425-428
Roentgen
AJR:168, February
of Maryland
Medical
detection
Previous
studies
injury
MD
oral
contrast
In general.
of
1997
been
bowel
requirement
that other
to detect
or direct
wall.
an
It
has
bowel
bowel
thickening
wall
indicate
or
the need
for
close observation
but not necessarily
immediate surgical
exploration
without
other definitive
131-
indications
The
of
clinical
the
injury
significance
mesentery
CT
scan.
included
injury
CT
unequivocally
ment
with
or
most
patients
with
require
evidence
surgical
associated
of isolated
small
by
a
of
who
managemesenteric
injuries
limited
on
injury
injury. Other CT studies
are
found
of mesenteric
bowel
without
injury
bowel
appropriate
when
studies
full-thickness
would
isolated
associated
is the
as
of this
Previous
have
of
without
is uncertain.
injury
visualiza-
indicate
of
hematoma,
concurrent
source.
surgery.
findings
full-
as pneumo-
known
as fixal
management
indicate
such
for
CT
f2-6I.
that
such
wall
I I 1.
abdominal
is useful
injury,
when
outcome
that
another
extrava.sation,
disrupted
suggested
findings
wall
without
oral contrast
intervention,
and mesentery
CT
bowel
peritoneum
unequivocal
Ray Society
material
f I J.
trauma
to improve
indicate
to the bowel
thickness
abdominal
and surgical
are critical
tion
0361-803X/97/1682-425
© American
of
Center, 22 S. Greene St., Baltimore,
correspondence
2Shock-Trauma
University
the
althoughand a
uncommon,
represents
sourcemesentery.
of morbidity
blunt
required.
with
1 Department
from
injury.
bowel
and can occur
sample
rnesenteric
size
or
425
Dowe
inclusion
of CT scans
peritoneal
lavage,
sensitivity
for
obtained
the
compromises
detection
injury [7, 8]. The goals
determine
the spectrum
mesentenc
injury,
mesenteric
injury
ful
mesenteric
and
require
Center
Medical
4 months.
from
with
registry
was
also
reviewed
Cl’
or possible
mesenteric
verified
study.
All
to identify
mesenteric
patients
A trauma
Redmond.
patients
with
included
injury
who
with
sur-
24 hr of
the initial CF scan except one. whose initial CT scan
was interpreted
as negative for mesenteric
injury.
This patient had a subsequent
deteriorating
clinical
course and had an additional CT scan 5 days after
admission
and immediately
before
surgery.
Patients
who had CT findings of mesenteric injury during the
study period were included
whether they were managed medically or surgically. We excluded laparotomy patients
in whom
CT showed full-thickness
bowel
injury
concurrent
with
mesenteric
injury
(n
=
diagnostic peritoneal
lavage
before CT (n = 2), and patients who did not have a
CT scan before surgery (n = 5). Of the 29 patients
who met the study criteria.
20 were men and 9 were
women: they ranged from 16 to 83 years old (mean
age, 39 years old). All patients had a history of blunt
3.
patients
abdominal
who
had
trauma.
records
and
sition
of the
surgical
reviewed
the patients’
reports
to determine
medithe
pelvic
the presence
ration and
mined
also
or absence
were
reviewed
for
sus.
The
scans
were
consensus
with
were
by consen-
interpretations
the original
reviewed
were
resolved
again
disclosed
were
later
interpretations.
after
the
to determine
The
surgical
if subtle
findfindings
were present but not recognized
on the initial
review. CI’ findings
suggestive
of mesenteric
injury
included stranding or opacification
of the mesenteric
fat (inhomogeneous
fluid density), intramesenteric
fluid collections
(uniform fluid density) or higher
attenuation hematoma, free intraperitoneal
fluid [9],
or evidence of active bleeding within the mesentery
and peritoneal cavity. The ranges of CT attenuation
values
used for the determination
of active hemorrhage and clotted blood were 85-370 H and 40-70
H,
respectively
[10].
Bowel
wall
thickening
of
Intraperitoneal
extravasation,
if identified on
initial interpretation,
lead to patient exclusion.
CT observations were correlated
with surgical
findings
to determine
the sensitivity
of CF for
detection of mesenteric injury and the usefulness of
greater
than 4 mm was also recorded.
free air or oral contrast
CF
findings
to
teric
avulsion
ing
mesentenc
thickness
toma,
discriminate
immediate
surgical
with
ischemic
vessels,
actively
full-thickness
bleedtears
of
focal
tear
with
be observed.
viable
The
bowel)
that
could
surgeon-author,
who
ischemia
or penfo-
was
the need for bowel
resection
as deter-
the surgical records to determine
which injuries
required surgery and which potentially did not. The
two patients who did not undergo laparotomy
were
followed up clinically.
at the time
reviewed
of surgery.
for evidence
Surgical
records
were
present
at one
third
of the surgeries.
were found between
cies
reviews
done
with
the retrospective
and
without
reviewed
Results
one case: a scan,
aflve, was found
infiltration
review.
and
At
originally
interpreted
to show homogeneous
of the mesentery
patients
27 patients
of
laparotomy
were
who
managed
had
the
after
29
study
CT.
The
by observation.
surgery,
24(89%)
patients
other
two
Of the
had
of
focally
surgery,
thickened
this
was
requiring
findings
CT
of
review
Both
patients
CT
that
verse
or repeated
outcome,
of
diagnostic
mesenteric
with
to
attributed
review,
of surgical
mesenteric
laceration
hematoma,
neither of
repair.)
The falsely
diagnosis
related
was
CT
by initial
(One patient
had a
tear at surgery,
and
in a patient
hematoma
two
either
had positive
the second
had a small
and pericecal
mesenteric
which
required
surgical
occurred
The
direct
did have intraperitoa visualized
source.
peritoneal
lavage
results.
distal jejunal
mesenteric
positive
to have
no
injury
knowledge
of these
loops.
found
had
retrospective
with
deteriorated,
dayS
later
resection.
studies
mesenteric
interpretation,
5
small-bowel
patient
bowel
as negfluid
on retrospective
This patient subsequently
a follow-up
CT obtained
showed
injury
a peripancreatic
pancreatic
transection
to an injury
of the
trans-
cases
was
with
92%
mesocolon.
On the basis of the 26 surgical
verified
mesenteric
injury,
CT
in detecting
the mesenteric
patients
followed
medically
of mesenteric
fluid density,
sensitive
(24/26)
The two
had CT findings
injury.
and one also had a small quantity
of free intraperitoneal
fluid. Both were managed
medically
hematocrit
were
subsequent
delayed
Among
fled
CT
stable.
Neither
surgical
the 26 patients
mesentenic
immediate
including
ischemic
bleeding
1 1).
The
other
mesenteric
(n
(n
1).
=
4),
=
4),
(n
mesentenic
gery, they
cal team,
yenthat
intervention,
10), actively
vessels
(n
=
mesentenic
injury
(n
=
=
surgical
patients
had
that did not require
surgical
partial-thickness
stable
mesentenc
or serosal
Although
lesions
five
injuries
including
surgically
had
surgical
avulsed
or
21
bowel
14), and full-thickness
required
patient
intervention.
with
injuries,
required
tears
Twenty-seven
CT
knowledge
the surgical
findings.
The retrospective
review
and the original
CT interpretation
disagreed
in
repair,
underwent
to be falsely
because
the clinical
examination
of the abdomen had benign results and the vital signs and
less serious injuries (partialcontusion,
stable hema-
laceration,
or serosal
injuries
(mesen-
bowel,
and
from
mesenteric
intervention
Sur-
confirmed.
CT scans
negative
in two other patients and falsely positive in one other patient. No major discrepan-
devitalized
adequate
of bowel
of active mesentenic
bleeding
or mesentenic
tears requiring repair.
CT scans were obtained on a conventional
scanner (HiQ; Siemens.
Iselin, Ni) or slip-ring
helical
scanner (Somatom Plus 4: Siemens). The CT scanner was adjacent to the admitting area of the trauma
center. All patients had to be hemodynamically
stable, as judged
by the admitting
clinical service.
before transfer
to the CF scanner.
Scans
were
426
for
injury
showed
although
one of the two
neal free fluid without
Disagreements
potentially
records
to allow
mesenteric
pretation.
CF.
surgical
images
of
findings
gical
opacification
of the bladder.
CF scans were reviewed
by two experienced
trauma radiologists
without knowledge
of surgical
findings
and without consulting
the original inter-
the mesentery)
Specifically,
PA) at a rate
contrast
symptoms and physical findings. specific
findings at surgery, and findings of diagnostic pentoneal lavage if performed before surgery but after
patients’
Pittsburgh.
findings
false-negative
requiring
We retrospectively
cal
IV: Medrad,
of 2-3 mllsec. A 30- to 40-sec delay was used for
conventional
scanning, and a 60-sec delay was used
for helical scanning. In addition, after helical scanning of the abdomen.
a 3- to 5-mm delay was used
between helical acquisition of the abdominal images
(to the level of the iliac crests) and sequential acqui-
ings
in the
within
(Mark
compared
had abdomi-
were included
to surgery
a
definite
All patients
surgery
went
mesenteric
Microsoft.
injury.
done before
of
to iden-
injury.
that
Mary-
and
1996. The
reviewed
force
interpretation
to the
of
obtained with sequential or helical 10-mm collimation at 10-mm intervals through the abdomen followed by sequential
10-mm
collimation
at 20-mm
intervals
through
the pelvis. All patients received a
single dose of oral contrast material (5 g of diatnizoate sodium [Hypaque; Nycomed, New York, NY]
powder dissolved in 355 ml ofwater) and 150 ml of
IV iohexol (Omnipaque
240; Winthrop-Breon
Pharmaceuticals,
Barcolenta,
PR) before scanning. The
IV contrast material was administered
by a power
injector
of 5 years
findings
blunt
(Access;
presurgical
CT
was
surgical
from
radiology database
University
a period
1990 to January
October
sustained
were admitted
the
during
data
tify patients
nal
versus
laparotomy
of
System
Shock-Trauma
gically
observa-
if CT findings
can be usewhich
patients
with
in this study
Shock-Trauma
WA)
surgical
of
Methods
All patients
injury
to
of
observation.
Materials
land
mesenteric
CT findings
with direct
injury
clinical
of
CT
of our study were
of CT findings
to compare
and to assess
in
predicting
tions,
after diagnostic
which
et al.
these
tears
with
injuries
mesentenic
hematomas
viable
were
bowel
treated
(n
=
at sun-
could, in the judgment
of the surgipotentially
have
been
managed
AJR:168, February 1997
Mesenteric
(Figs.
Injury
After
2 and 3), seen
patients
with
Blunt
in five cases.
mesenteric
bleeding
of the
had
the
active
of surgery,
ischemic
CT plays a major
mesen-
patients
and five
bowel
requiring
associated
mesenteric
with mesen-
hematoma
(Figs.
4) and infiltration
density
tially
of the mesentery
5). Free intraperitoneal
(Fig.
source,
another
such
was not unique
with
fluid
as visceral
to patients
injury,
whose
inju-
surgery but were seen commonly
patients with
both
(n
surgically
nonsurgically
(n
managed
in
and poten-
=
8)
=
3) mesenteric
the
teric
mesenteric
five
patients
ing
surgical
visceral
conservatively.
cases
injury at surgery
The CT findings
are summarized
Two
whose
CT
in Table
findings
injuries
extravasation
as possible
were
required
all surgical
I.
injury.
findings
to
repair:
material
and 2), seen in seven cases, and bowel wall
thickening
associated
with mesenteric
findings
1
but CT
findings
requiring
with
injuries
not
repair.
bowel
the assertion
peripancreatic
tenderness
CT scans
(n
=
repair.
findings
interpretation
bowel
injuries
=
3),
hypoactive
=
physical
not have
were variably
present. The two patients managed
without
surgery had clinical
assessments
whose
results
were initially
and persistently
benign.
from
those
requiring
could
observation
and
free
of
CT
could
poten-
mesenteric
surgical
be
these
had the CT
changed
to discriminate
at
interven-
management
oral
conserva-
CT findings
contrast
con-
material
of loss of bowel
intraperitoneal,
and
intervention
managed
injury.
sistent with extravasated
rity:
surgical
false-negative
surgical
been
tively 12. 3]. In bowel
direct
required
to the mesentery
been positive.
proposed
that
that
associated
injury nonethetransection
with
with
injuries
the
may
the
requir-
I ). and
Therefore,
patients
that
patients
did have
be used
findings
without
but neither required
tially
2) were recorded.
Among the
16 patients
whose injuries
required
(ii
Both
It has been
physical
tenderness (n
hematoma
exploration.
injury
Among
for use in the identifi-
injuries
positive CT scan for mesenteric
less had sustained
a pancreatic
physical
necessarily
positive
rebound
sounds
benign
of mesenteric
surgical
repair.
well with
of the mesen-
with
diffuse abdominal
surgical
active
(Figs.
patients
including
remaining
patients
Six
had lesions
bowel
unique
surgical
of IV contrast
in
cause.
did not correlate
type and clinical significance
fluid collection
or hematoma
is defined as uniform fluid density of low or high attenuation,
respectively.
aWithout
active extravasation
of contrast agent.
bwith
neither active extravasation
of contrast agent nor
fluid or hematoma.
or
support
tool
of mesenteric
tion.
Physical findings
as inhomoge-
is a sensitive
cation
surgery,
injuries.
cWithout
mesenteric
results
and two a false-negative
CT scan
injury. The patient with the false-
included
ries required
fat; intramesenteric
Our
false-positive
for mesenteric
bowel at surgery.
identified
the mesenteric
suspected
of
abdominal
bowel injuries.
Of the 27 surgicases in our study. one had had a
without
within
[1-4].
blunt
full-thickness
cally proven
fluid
neous fluid density
and
injury
in the evaluation
of
ischemic
3 and
is defined
trauma
role
a history
that CT
The other CT findings
infiltration
with
resection. Among the five patients
with bowel
wall thickening
identified
by CT. four had
teric injury
Note.-Mesenteric
Discussion
extravasation
had
at the time
seven
Among
contrast
seen on CT. six of the seven
teric
Trauma
wall
integ-
intermesenteric,
or
intramural
gas without
a known source would
indicate
a need for urgent surgery.
Thickened
bowel
abdominal
loops
alone
in the setting
examination
could be observed
with
of a clinical
benign
121. In mesenteric
results
injury,
this
Fig. 1.-41 -year-old man with extravasation
of vascular
contrast
agent into mesentery.
Enhanced
CT scan
shows high-density
material (arrows) within lower den-
sity mesenteric hematoma, indicating active bleeding.
Active bleeding 10 cm from ileocecal
valve was confirmed at surgery. Patient required resection of ischemic and devitalized terminal ileum.
Fig. 2.-83-year-old
man with active mesenteric bleed-
ing. CT scan shows active mesenteric
bleeding (arrow)
and adjacent thick-walled
loops of bowel (arrowhead)
as well as active bleeding into gluteal muscle in proximity of right iliac wing fracture (open arrow). At surgery,
patient required
ligation of actively bleeding vessels,
and thick-walled
bowel was found not to be devitalized.
Fig. 3-27-year-old man with blunt trauma.
A, Enhanced admission CT scan shows characteristic
triangular shape of high-attenuation
mesenteric hematoma (arrow)
caught between adjacent leaves of mesentery. This CT scan was initially interpreted as negative for
mesenteric injury.
B, Follow-up CT scan on same patient, who had subsequent deteriorating
clinical
admission CT scan shows
associated
with ischemic
course, obtained 5 days after
findings of mesenteric
injury
small bowel. Enhanced
CT
scan shows focal bowel wall thickening (solid arrow),
thickened
folds, and two small foci of intramesenteric
fluid (open arrows). This section of ileum was found to be
devitalized at surgery and was resected.
AJR:168,
February
1997
427
Dowe
et al.
Fig. 4-57-year-old
woman with intramesenteric
hematomas. Enhanced CT scan shows typical triangular
hematomas
(arrows)
between
mesenteric
folds. At
surgery,
small mesenteric
tears were found adjacent
to focal hematomas.
Fig. 5.-48-year-old
man with infiltration of mesenteric fat Enhanced CT scan shows opacification
oftransverse mesocolon
(arrows).
At surgery,
this area of
mesentery was found to have full-thickness
to be bleeding. Adjacenttransverse
tear and focally ischemic.
study
shows
that
contrast material
injury
indicates
1w’ compromise
bowel
ongoing
as
well
dates
compromise
of
infiltration
likelihoxl
bowel
and
significance
of mesenteric
of the less
injury.
such
of
man-
teric hematoma
and
within
the mesentery.
study. Some
did
repair.
son,
we
should
=
lesions requiring
=
6) had
For this rca-
others
these
CT
(ii
as the
findings
sole
alone
criteria
for
determining
with
the need for laparotomy.
Patients
mesenteric
hematoma
or fluid without
adjacent
bowel
surgical
indications
tion
should
follow-up
wall
428
from
be carefully
CT
within
scopic
evaluation
exploration.
Our
also
thickening
indicated
and
physical
observed,
without
examina-
undergo
24 hr. undergo
laparo-
111. 121. or have
review
of medical
surgical
records
that
initial
physical
findings
or
adjacent
the
blunt
likelihood
bowel
and can occur
lesions
that
of a
delayed
repeat
wall thickening
with both
require
those that do not. In those
clinical
observation
and
including
in
a high
injury requiring
surgery. The
mesenteric
hematoma
or infil-
without
tery-bowel
bleeding
and
with mesen-
infiltration
indicates
is nonspecific
(ii
ischemia.
teric hematoma
trauma
victim
tration
with these findings
bowel
believe
that
not be used
signs
mesendensity
by this
whereas
life-threatening
The CT finding of mesenteric
bowel wall thickening
associated
mesentery-bowel
finding of focal
isolated
fluid
is not clarified
mesenteric
have
not
surgical
patients
striking
as isolated
injuries.
Conclusion
of local
adjacent
exploration.
The
6)
the
with mesenteric
the
mandating
the association
combined
with
mesenteric
hematonia
or mesenteric
in our study also indicates
a high
vascular
as
alone were a poor guide for deciding
between
surgical
and
nonsurgical
management
of
patients
for vascu-
hemorrhage
exploration.
Similarly.
bowel
wall thickening
IV
from vascular
the potential
of the
for
extrava.sated
in the niesentery
strongly
potential
identifying
surgery
and
CT,
lap-
aroscopy, or possible
exploration
are recommended.
Our impression
was that the use of
oral contrast
material
to make the small-bowel
lumen
opaque
mesenteric
was
lesions
helpful
and
bowel
in
wall
DD.
identifying
thickening.
MP. Gniffiths
tomography
BG. Trunkey
in the diagnosis
injuries.
of
J Trauma
D. Federle MP. Localized
clotted blood as
evidence
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