Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic–therapeutic algorithm

Abstract

Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

“…Patients who scored five or higher had an 11-fold increase of bowel injury requiring surgical exploration (AUC was 0.98). Similarly, Bonomi and co-workers developed six criteria for detecting hollow viscus and mesenteric injury requiring surgical repair [ 1 ]. Their criteria were: free air, free fluid without solid organ injury, intra-mesenteric fluid, contrast extravasation (blush), bowel wall abnormality (including thickening) and mesenteric alteration (including stranding).…”

“…Similarly, in a cohort of 195 blunt trauma patients with hollow viscus injury, a delay of more than 5 h between admission and laparotomy was linked to an increased risk of mortality [ 118 ]. One more cohort of 62 blunt trauma patients with bowel injury showed an association between a delay of more than 8 h to surgical treatment and higher rates of serious complications (27% vs 61%; p < 0.01) and sepsis (16% vs 28%; p = 0.03) [ 1 ]. The findings of these studies highlight the importance of prompt decision making in all trauma situations, whether a patient arrives immediately to hospital following injury or there is a delay to presentation.…”

“…Traumatic hollow viscus and mesenteric injury are relatively uncommon, with a prevalence of approximately 1% in blunt trauma and 17% in penetrating trauma [ 1 ]. Following blunt and penetrating trauma, and especially in the context of multiple other injuries, hollow viscus and mesenteric injuries pose a clinical challenge mainly due to their relative infrequency, diagnostic uncertainties, and deleterious consequences when not promptly treated.…”

A Retrospective Cohort Study on the Clinical Characteristics of Patients with Surgical Blunt Bowel and/or Mesenteric Injuries among Motorcyclists and Car Occupants

“…In addition, given the lack of a protocol regarding the management of BBMI, the present study failed to obtain complete information about the CT examination with respect to its timing and protocol. However, although abdominal CT may be critical for diagnosing BBMI [ 32 ], this study only enrolled surgical BBMI patients who were proven surgically following laparotomy, thus excluding the possible ambiguous diagnosis that relies solely on imaging studies. Despite these limitations, this study may provide useful information on this rare disease called surgical BBMI following motorcycle and car traffic accidents.…”

Late Presentation of Peritonitis Post Jejunal Perforation Due to Flank Stab Wound

“…Hence, increasing morbidity and mortality rates [ 12 ]. Physicians should look for signs of peritonitis, which presents earlier in gastric perforation [ 13 ]. However, small intestine perforation tends to take a longer period for signs and symptoms to surface.…”