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Basic mechanisms of bowel and mesenteric injuries
• Shearing injuries caused by deceleration
• Crush injuries from direct impact
• Burst injuries from sudden increases in
intraluminal pressure
Ultrasound examination
• Free fluid
• Pneumoperitoneum
• Air in bowel wall
• Wall thickening of bowel loops
CT Technique
• IV contrast (100-120 ml)• Portal venous phase (70 second delay)• Delay film (7 minute)• Oral contrast +/_• Rectal contrast +/_
CT signs of bowel loops injury
• Wall transection with focal discontinuity (spe:100%& sen:7%)
• Extraluminal oral contrast
• Pneumoperitoneum (20-75%)
• Pneumoretroperitoneum
• Focal wall thickening
• Abnormal wall enhancement
• Ill defined increased attenuation of mesentry
• Intra peritoneal fluid
Other causes of pneumoperitoneum
• Bladder rupture with an indwelling Foley catheter
• Massive pneumothorax
• Barotrauma
• Benign pneumoperitoneum
• Peritoneal lavage
• Pseudopneumoperitoneum (air between abdominal wall and parietal peritoneum)
Diffuse bowel wall thickening
• Fluid over load– Liver inhomogeneous enhancement(nutmeg appearance)– Periportal edema
• Hypoperfusion complex(shock bowel)– Flat IVC– Increased enhancement of adrenal gland– Retroperitoneal edema
Diffuse thickening and hyperenhancementof the loops due to aggressive resuscitation with
intravenous fluids
Duodenal injuries
• More secondary to penetrating injuries and less likely due to blunt trauma
• CT findings: wall thickening, discontinuity, contrast extravasation, fluid adjacent to the duodenum and pancreatic head and retroperitoneum air or fluid
Colonic injuries
• Wall transection with focal discontinuity• Contrast extravasation • Pneumoperitoneum• Pneumoretroperitoneum • Focal wall thickening• Abnormal wall enhancement• Ill defined increased attenuation of mesentry• Intra peritoneal fluid
Sign mesenteric trauma
• Mesenteric hematoma
• Intraperitoneal extravasation of intravenous contrast
• Abrupt termination of mesenteric vessels
• Unequivocal irregularity of the wall of mesenteric vessels
• Increased attenuation of the mesentery
abnormally positioned in the right hemiabdomen , with subtle stranding of the corresponding mesentery due to
traumatic internal hernia
Anorectal injury
• Mortality rate three times more than colonic injury
• Associated with pelvic fracture
• concomitant with bladder, urethral and vascular injuries
• Divided into intraperitoneal and extraperitoneal
Injury of mesentery and mesenteric vessels
• Extravasation of IV contrast
• Mesentric hematoma
• Mesentric infiltration
• Beading or abrupt termination of mesentric vessels
• Mesentric rent with internal hernia
Causes of retroperitoneal air
• Colonic perforation (ascending and descending)
• Duodenal injuries
• Pneumothorax
• Pneumomediastinum
Free peritoneal fluid
• Most common finding (most sensitive)
• Absence of free fluid excludes surgical important injury
• The attenuation is highest in the vicinity of the injured organ (sentinel clot)
• Localized fluid (triangle sign)
• Attenuation of hemoperitoan is high (>30-40) , simple fluid H.U is about 13