(Radiographics. 2000;20:1536-1537.)
© RSNA, 2000
Invited Commentary
Stuart E. Mirvis, MD
Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
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Introduction
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The past decade has seen an increasing trend toward nonsurgical management of abdominal blunt traumatic injury. This development has been primarily brought about by the ability of computed tomography (CT) to depict the presence and extent of solid organ injury and to monitor the progression or resolution of that injury over time. Nonsurgical management, particularly of liver and spleen injury in hemodynamically stable patients, has become common state-of-the-art practice. As CT scanning has progressed from conventional single section, to single row detector helical, and now to multirow detector helical, its sensitivity to depict and help characterize abdominal organ injury has improved.
Identification of conditions that would indicate a potentially poor outcome for nonsurgical management of abdominal solid organ injury is key to minimize patient morbidity and mortality. The presence of a CT "blush" or intraparenchymal contrast material extravasation has been established as a definite indicator of likely failure of nonsurgical treatment (1). Another major potential source of failure is a missed bowel or mesenteric injury. CT studies performed in the early to middle 1980s did not demonstrate high sensitivity or specificity for these injuries. Subsequently, improvement in CT technology (faster thinner section profile), timing of intravenous administration of a bolus of contrast material, use of oral contrast material, and a greater awareness of CT signs of bowel and mesenteric injury fostered improved diagnostic accuracy through the 1990s.
Still, many of our clinical colleagues remain unconvinced that CT can in fact help find or reliably exclude bowel and mesenteric injuries. This pictorial essay presented by Brody et al
does a wonderful job of illustrating the CT findings of bowel and mesenteric injury and their frequency and also of emphasizing where diagnostic mistakes are likely to be made. Spreading this practical article among fellow radiologists would enhance its value to the radiology community.
It is clear that use of the several CT signs described in this essay requires a careful review of the individual CT images. A dedicated search for small collections or bubbles of intraperitoneal free air is essential. The use of bone window settings improves the ease of detection by helping to distinguish the attenuation of fat from that of adjacent air. A careful search for free fluid in the gravity-dependant portions of the peritoneal space is required. The presence of a small amount of free fluid, although not associated with a high frequency of bowel or mesenteric injury, should still be regarded with suspicion and careful follow-up performed. The bowel loops and intervening mesentery should be inspected for wall thickening, infiltration, intramesenteric fluid (mesenteric triangles) (2), and irregular or atypical enhancement. All this is time-consuming but truly necessary because bowel and mesenteric injuries can often appear with subtle manifestations. In any circumstance in which there is a questionable CT sign suggestive of bowel or mesenteric injury, follow-up with CT (612 hours), clinical and laboratory reassessment, repeat abdominal ultrasonography (US) in experienced hands, and perhaps diagnostic peritoneal lavage could all be used. Typically at our institution, a combination of clinical and laboratory reassessment and repeat CT is used. Evidence at CT of progression of signs of bowel or mesenteric injury results in abdominal exploration, particularly if accompanied by deterioration in clinical signs. At the Maryland Shock-Trauma Center (Baltimore), essentially all trauma patients undergoing abdominopelvic CT are given gastrointestinal contrast material orally or via a nasogastric tube, and essentially no complications have been described in the past 15 years.
Although CT imaging technology and interpretation have improved greatly in the past decade for detection or exclusion of bowel and mesenteric injury, the question remains as to how reliably CT itself can help distinguish surgical from nonsurgical bowel and mesenteric injury. Findings of full-thickness bowel injury, persistent bleeding from the bowel or mesentery, or clearly ischemic bowel are definite operable lesions. Appropriate management for other findings, such as a mesenteric or bowel-wall hematoma or contusion, without other signs is less clear and requires further study. The following are a few other questions that need more investigation. Do all patients with CT signs of bowel or mesenteric injury who remain clinically stable with no or resolved clinical abdominal signs require repeat CT before discharge? Does the exclusion of free fluid in the abdomen at initial CT or US assessment eliminate significant bowel and mesenteric injury? To what extent are CT signs of bowel and mesenteric injury manifest well after the initial CT examination?
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References
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Schurr MJ, Fabian TC, Gavant M, et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J Trauma 1995; 39:507-513.[Medline]
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Levine CD, Gonzales RN, Wachsberg RH. CT findings in bowel and mesenteric injury. J Comput Assist Tomogr 1997; 21:974-979.[Medline]
Related Article
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CT of Blunt Trauma Bowel and Mesenteric Injury: Typical Findings and Pitfalls in Diagnosis
- Jeffrey M. Brody, Danielle B. Leighton, Brian L. Murphy, Gerald F. Abbott, Jonathan P. Vaccaro, Liudvikas Jagminas, and William G. Cioffi
RadioGraphics 2000 20: 1525-1536.
[Abstract]
[Full Text]
[PDF]
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Introduction
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