CT of Bowel and Mesenteric Trauma in Children1
Peter J. Strouse, MD,
Bradley J. Close, MD,
Kelley W. Marshall, MD and
Robert Cywes, MB, ChB
1 From the Section of Pediatric Radiology, Department of Radiology (P.J.S., B.J.C., K.W.M.), and Section of Pediatric Surgery, Department of Surgery (R.C.), C.S. Mott Children's Hospital, F3503, University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0252. Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received February 26, 1999; revision requested March 11 and received April 26; accepted May 3. Address reprint requests to P.J.S.
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Figure 1a. Lap belt injury in a 16-year-old girl after a motor vehicle accident in which she was a backseat passenger. A Chance fracture of the third lumbar vertebra was seen on radiographs and scout CT scans. (a) Photograph shows prominent lap belt ecchymosis. (b) CT scan shows disruption of the rectus muscles and a diffuse traumatic hernia of the anterior abdominal wall (arrows). Fluid at the mesenteric root and moderate free intraperitoneal fluid were noted on other sections. No free intraperitoneal air or bowel wall thickening was seen. At surgery, multiple mesenteric defects were found with extensive areas of devascularization of the small intestine, cecum, and sigmoid colon. Most of the intestine was resected.
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Figure 1b. Lap belt injury in a 16-year-old girl after a motor vehicle accident in which she was a backseat passenger. A Chance fracture of the third lumbar vertebra was seen on radiographs and scout CT scans. (a) Photograph shows prominent lap belt ecchymosis. (b) CT scan shows disruption of the rectus muscles and a diffuse traumatic hernia of the anterior abdominal wall (arrows). Fluid at the mesenteric root and moderate free intraperitoneal fluid were noted on other sections. No free intraperitoneal air or bowel wall thickening was seen. At surgery, multiple mesenteric defects were found with extensive areas of devascularization of the small intestine, cecum, and sigmoid colon. Most of the intestine was resected.
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Figure 2a. Bicycle handlebar injury in a 7-year-old boy. (a) Photograph shows focal ecchymosis in the left upper quadrant due to the impact of the end of a handlebar. (b) CT scan shows focal bowel wall thickening in the same region (arrows). A small amount of free fluid was present in the left upper quadrant and pelvis. A jejunal perforation was found at surgery. (Case not included in the Clinical Experience section or in the Table. Courtesy of Kathleen Emery, MD, Children's Hospital Medical Center, Cincinnati, Ohio.)
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Figure 2b. Bicycle handlebar injury in a 7-year-old boy. (a) Photograph shows focal ecchymosis in the left upper quadrant due to the impact of the end of a handlebar. (b) CT scan shows focal bowel wall thickening in the same region (arrows). A small amount of free fluid was present in the left upper quadrant and pelvis. A jejunal perforation was found at surgery. (Case not included in the Clinical Experience section or in the Table. Courtesy of Kathleen Emery, MD, Children's Hospital Medical Center, Cincinnati, Ohio.)
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Figure 3a. Confirmed child abuse in an 18-month-old girl with an initial history of "falling down steps." CT scans show a markedly irregular distal duodenum (black arrowheads) and marked diffuse mesenteric stranding (M in b) and free fluid (F). Small bubbles of free intraperitoneal air are present anteriorly (white arrowheads). The proximal jejunum is dilated (J in b). At surgery, a transection was found at the duodenal-jejunal junction.
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Figure 3b. Confirmed child abuse in an 18-month-old girl with an initial history of "falling down steps." CT scans show a markedly irregular distal duodenum (black arrowheads) and marked diffuse mesenteric stranding (M in b) and free fluid (F). Small bubbles of free intraperitoneal air are present anteriorly (white arrowheads). The proximal jejunum is dilated (J in b). At surgery, a transection was found at the duodenal-jejunal junction.
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Figure 4a. Increasing pain and fever in a 5-year-old boy with a 2-week history of gastrointestinal distress. CT was performed to "r/o [rule out] appy [appendectomy] vs. abscess." (a) CT scan shows an ill-defined mass (H) within the mesentery. The abnormality extends to the mesenteric root. A large amount of free fluid (F) is present, mainly within the pelvis. The anterior ends of several ribs were irregular and probably fractured. (b) CT scan shows a fracture of the left anterior sixth rib (arrow). The slight expansion of the right anterior sixth rib (?) distinguishes this rib from the adjacent ribs and was likely due to previous fracture. At surgery, a mesenteric tear with a large hematoma was found. Child abuse was subsequently substantiated.
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Figure 4b. Increasing pain and fever in a 5-year-old boy with a 2-week history of gastrointestinal distress. CT was performed to "r/o [rule out] appy [appendectomy] vs. abscess." (a) CT scan shows an ill-defined mass (H) within the mesentery. The abnormality extends to the mesenteric root. A large amount of free fluid (F) is present, mainly within the pelvis. The anterior ends of several ribs were irregular and probably fractured. (b) CT scan shows a fracture of the left anterior sixth rib (arrow). The slight expansion of the right anterior sixth rib (?) distinguishes this rib from the adjacent ribs and was likely due to previous fracture. At surgery, a mesenteric tear with a large hematoma was found. Child abuse was subsequently substantiated.
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Figure 5. Free intraperitoneal air in a 14-year-old boy with a bicycle handlebar injury. CT scan shows a small amount of free fluid (F). The free fluid and subtle bowel wall thickening (seen on other images) were considered equivocal findings. However, the presence of small bubbles of free intraperitoneal air (arrowheads) confirms the diagnosis of bowel perforation.
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Figures 6, 7. (6) Free intraperitoneal air in a 16-year-old boy who was hit by an automobile. CT scans show a large amount of free intraperitoneal fluid (F), which is not accounted for by parenchymal or osseous pelvic injury. There is slight bowel wall thickening (arrows in a). A tiny bubble of extraluminal gas is seen anteriorly (arrowhead in b). Fluid is seen at the mesenteric root (M in a). Two sites of small bowel perforation and a degloving injury of the sigmoid colon were found at surgery. (7) Free intraperitoneal air in a 6-year-old boy with abdominal pain after a motor vehicle accident. The patient was treated conservatively for 3 days. CT was performed due to increasing pain and new fever. CT scans show free intraperitoneal fluid (F), free intraperitoneal air (arrowheads in a), bowel wall thickening (arrows), and mesenteric stranding (M), which are indicative of bowel perforation with peritonitis.
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Figures 6, 7. (6) Free intraperitoneal air in a 16-year-old boy who was hit by an automobile. CT scans show a large amount of free intraperitoneal fluid (F), which is not accounted for by parenchymal or osseous pelvic injury. There is slight bowel wall thickening (arrows in a). A tiny bubble of extraluminal gas is seen anteriorly (arrowhead in b). Fluid is seen at the mesenteric root (M in a). Two sites of small bowel perforation and a degloving injury of the sigmoid colon were found at surgery. (7) Free intraperitoneal air in a 6-year-old boy with abdominal pain after a motor vehicle accident. The patient was treated conservatively for 3 days. CT was performed due to increasing pain and new fever. CT scans show free intraperitoneal fluid (F), free intraperitoneal air (arrowheads in a), bowel wall thickening (arrows), and mesenteric stranding (M), which are indicative of bowel perforation with peritonitis.
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Figures 6, 7. (6) Free intraperitoneal air in a 16-year-old boy who was hit by an automobile. CT scans show a large amount of free intraperitoneal fluid (F), which is not accounted for by parenchymal or osseous pelvic injury. There is slight bowel wall thickening (arrows in a). A tiny bubble of extraluminal gas is seen anteriorly (arrowhead in b). Fluid is seen at the mesenteric root (M in a). Two sites of small bowel perforation and a degloving injury of the sigmoid colon were found at surgery. (7) Free intraperitoneal air in a 6-year-old boy with abdominal pain after a motor vehicle accident. The patient was treated conservatively for 3 days. CT was performed due to increasing pain and new fever. CT scans show free intraperitoneal fluid (F), free intraperitoneal air (arrowheads in a), bowel wall thickening (arrows), and mesenteric stranding (M), which are indicative of bowel perforation with peritonitis.
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Figures 6, 7. (6) Free intraperitoneal air in a 16-year-old boy who was hit by an automobile. CT scans show a large amount of free intraperitoneal fluid (F), which is not accounted for by parenchymal or osseous pelvic injury. There is slight bowel wall thickening (arrows in a). A tiny bubble of extraluminal gas is seen anteriorly (arrowhead in b). Fluid is seen at the mesenteric root (M in a). Two sites of small bowel perforation and a degloving injury of the sigmoid colon were found at surgery. (7) Free intraperitoneal air in a 6-year-old boy with abdominal pain after a motor vehicle accident. The patient was treated conservatively for 3 days. CT was performed due to increasing pain and new fever. CT scans show free intraperitoneal fluid (F), free intraperitoneal air (arrowheads in a), bowel wall thickening (arrows), and mesenteric stranding (M), which are indicative of bowel perforation with peritonitis.
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Figure 8a. Free retroperitoneal air in a 7-year-old boy after a motor vehicle accident. Copies of CT scans (marks included) from the referring institution show not only free intraperitoneal air (arrows) but also free retroperitoneal air (arrowheads). Free intraperitoneal fluid (F in b) and mesenteric stranding (M in b) are also seen. At surgery, perforations were found in the distal duodenum and the hepatic flexure of the colon.
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Figure 8b. Free retroperitoneal air in a 7-year-old boy after a motor vehicle accident. Copies of CT scans (marks included) from the referring institution show not only free intraperitoneal air (arrows) but also free retroperitoneal air (arrowheads). Free intraperitoneal fluid (F in b) and mesenteric stranding (M in b) are also seen. At surgery, perforations were found in the distal duodenum and the hepatic flexure of the colon.
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Figure 9. Extraluminal oral contrast material in a 6-year-old boy after a motor vehicle accident. CT scan shows a thin rim of high attenuation peripheral to the liver (arrows); this finding presumably represents extraluminal oral contrast material. Free fluid was seen within the pelvis, and there was slight bowel wall thickening in the lower abdomen. The bladder was intact. A perforation of the ileum was found at surgery.
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Figures 10-12. (10) Bowel wall thickening in a 4-year-old boy who was ejected from an automobile during a high-speed motor vehicle accident. CT scan shows focal small bowel thickening on the left side (arrows). Note the fluid at the mesenteric root (M). There is a moderate amount of free fluid (F); the free fluid was predominantly located within the pelvis. A small jejunal perforation was found at surgery. (11) Bowel wall thickening in a 6-year-old boy who suffered a direct blow to the right lower quadrant during a motor vehicle accident. CT scan shows a thickened bowel wall in the right lower quadrant (arrows) with underlying mesenteric stranding (M). Note the small hematoma around the mesenteric vessels (arrowheads). F = free intraperitoneal fluid. At laparoscopy, a small area of jejunal infarction and perforation that corresponded to the CT abnormality was seen. This area was repaired laparoscopically. (12) Bowel wall thickening in a 17-year-old girl with complex pelvic fractures from a motor vehicle accident. An extraperitoneal bladder rupture was demonstrated with cystography. Owing to the contrast material load from angiography and pelvic embolization, the subsequent abdominal CT study was performed without additional intravenous contrast material. CT scan shows free intraperitoneal air (arrowheads). Despite the absence of contrast material, bowel wall thickening is seen on the right side (arrows). Note the difference in comparison with the imperceptible bowel wall on the left side. An ileal perforation was found at surgery.
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Figures 10-12. (10) Bowel wall thickening in a 4-year-old boy who was ejected from an automobile during a high-speed motor vehicle accident. CT scan shows focal small bowel thickening on the left side (arrows). Note the fluid at the mesenteric root (M). There is a moderate amount of free fluid (F); the free fluid was predominantly located within the pelvis. A small jejunal perforation was found at surgery. (11) Bowel wall thickening in a 6-year-old boy who suffered a direct blow to the right lower quadrant during a motor vehicle accident. CT scan shows a thickened bowel wall in the right lower quadrant (arrows) with underlying mesenteric stranding (M). Note the small hematoma around the mesenteric vessels (arrowheads). F = free intraperitoneal fluid. At laparoscopy, a small area of jejunal infarction and perforation that corresponded to the CT abnormality was seen. This area was repaired laparoscopically. (12) Bowel wall thickening in a 17-year-old girl with complex pelvic fractures from a motor vehicle accident. An extraperitoneal bladder rupture was demonstrated with cystography. Owing to the contrast material load from angiography and pelvic embolization, the subsequent abdominal CT study was performed without additional intravenous contrast material. CT scan shows free intraperitoneal air (arrowheads). Despite the absence of contrast material, bowel wall thickening is seen on the right side (arrows). Note the difference in comparison with the imperceptible bowel wall on the left side. An ileal perforation was found at surgery.
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Figures 10-12. (10) Bowel wall thickening in a 4-year-old boy who was ejected from an automobile during a high-speed motor vehicle accident. CT scan shows focal small bowel thickening on the left side (arrows). Note the fluid at the mesenteric root (M). There is a moderate amount of free fluid (F); the free fluid was predominantly located within the pelvis. A small jejunal perforation was found at surgery. (11) Bowel wall thickening in a 6-year-old boy who suffered a direct blow to the right lower quadrant during a motor vehicle accident. CT scan shows a thickened bowel wall in the right lower quadrant (arrows) with underlying mesenteric stranding (M). Note the small hematoma around the mesenteric vessels (arrowheads). F = free intraperitoneal fluid. At laparoscopy, a small area of jejunal infarction and perforation that corresponded to the CT abnormality was seen. This area was repaired laparoscopically. (12) Bowel wall thickening in a 17-year-old girl with complex pelvic fractures from a motor vehicle accident. An extraperitoneal bladder rupture was demonstrated with cystography. Owing to the contrast material load from angiography and pelvic embolization, the subsequent abdominal CT study was performed without additional intravenous contrast material. CT scan shows free intraperitoneal air (arrowheads). Despite the absence of contrast material, bowel wall thickening is seen on the right side (arrows). Note the difference in comparison with the imperceptible bowel wall on the left side. An ileal perforation was found at surgery.
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Figure 13a. Focal hematoma in a 4-year-old boy with a lap belt injury. (a) CT scan shows fluid distending the proximal duodenum (arrow). (b) CT scan shows a periduodenal or intramural hematoma (H). (c) Radiograph from an upper gastrointestinal study shows complete obstruction due to the hematoma (arrowheads).
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Figure 13b. Focal hematoma in a 4-year-old boy with a lap belt injury. (a) CT scan shows fluid distending the proximal duodenum (arrow). (b) CT scan shows a periduodenal or intramural hematoma (H). (c) Radiograph from an upper gastrointestinal study shows complete obstruction due to the hematoma (arrowheads).
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Figure 13c. Focal hematoma in a 4-year-old boy with a lap belt injury. (a) CT scan shows fluid distending the proximal duodenum (arrow). (b) CT scan shows a periduodenal or intramural hematoma (H). (c) Radiograph from an upper gastrointestinal study shows complete obstruction due to the hematoma (arrowheads).
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Figures 14, 15. (14) Focal hematoma in a 5-year-old girl with a 12-hour history of increasing abdominal pain and vomiting. She had fallen against bicycle handlebars 36 hours earlier. CT scan shows a large duodenal-jejunal hematoma (H, arrows). (15) Focal hematoma in a 6-year-old boy with a 3-day history of vomiting. He had had an on-ice collision with his hockey coach 2 weeks earlier. The serum amylase level was normal. CT scan shows a large mass (H) in the left upper quadrant that drapes over bowel loops (B). An upper gastrointestinal study showed complete obstruction due to the mass. The mass was thought to be a large intramural jejunal hematoma. The patient was initially treated conservatively and received total parenteral nutrition. However, the symptoms did not improve and the mass persisted, and thus it was drained percutaneously. The contents were consistent with old blood and showed no amylase.
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Figures 14, 15. (14) Focal hematoma in a 5-year-old girl with a 12-hour history of increasing abdominal pain and vomiting. She had fallen against bicycle handlebars 36 hours earlier. CT scan shows a large duodenal-jejunal hematoma (H, arrows). (15) Focal hematoma in a 6-year-old boy with a 3-day history of vomiting. He had had an on-ice collision with his hockey coach 2 weeks earlier. The serum amylase level was normal. CT scan shows a large mass (H) in the left upper quadrant that drapes over bowel loops (B). An upper gastrointestinal study showed complete obstruction due to the mass. The mass was thought to be a large intramural jejunal hematoma. The patient was initially treated conservatively and received total parenteral nutrition. However, the symptoms did not improve and the mass persisted, and thus it was drained percutaneously. The contents were consistent with old blood and showed no amylase.
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Figures 16, 17. (16) Focal hematoma in a 13-month-old girl with an initial history of "fall from couch." Later, child abuse was confirmed. CT scan shows a mesenteric hematoma (H). The patient also had a liver contusion, a renal contusion, a skull fracture, a subdural hematoma, and bilateral retinal hemorrhage. (17) Focal hematoma in a 7-year-old boy with lap belt ecchymosis. CT scan shows a hematoma (H) surrounding the distal superior mesenteric artery and vein. The patient was treated conservatively. The finding had resolved at follow-up CT performed 1 month later.
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Figures 16, 17. (16) Focal hematoma in a 13-month-old girl with an initial history of "fall from couch." Later, child abuse was confirmed. CT scan shows a mesenteric hematoma (H). The patient also had a liver contusion, a renal contusion, a skull fracture, a subdural hematoma, and bilateral retinal hemorrhage. (17) Focal hematoma in a 7-year-old boy with lap belt ecchymosis. CT scan shows a hematoma (H) surrounding the distal superior mesenteric artery and vein. The patient was treated conservatively. The finding had resolved at follow-up CT performed 1 month later.
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Figure 18. Active hemorrhage in a 9-year-old boy who was ejected from an automobile during a motor vehicle accident. CT scan shows evidence of active bleeding into the mesentery (arrowheads), thickening of the bowel wall (arrow), fluid at the mesenteric root (M), and free fluid (F). At surgery, a large ileal mesenteric tear was found with ischemia of the ileum and mesoappendix but no perforation.
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Figure 19. Mesenteric pseudoaneurysm in an 8-year-old boy who was hemodynamically stable after a head-on motor vehicle accident in which he was restrained. CT scan shows a large hematoma (H) in the midabdomen on the right side with an enhancing pseudoaneurysm (*) and evidence of active hemorrhage (arrowheads). F = free intraperitoneal fluid. At surgery, a large mesenteric tear with right colonic ischemia was found.
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Figures 20, 21. (20) Hypoperfusion complex in an 8-year-old boy after a motor vehicle accident. The patient appeared to be in stable condition on entering the CT scanner but experienced cardiac arrest during scanning (after this image was obtained) and could not be resuscitated. CT scan shows diffuse distended small intestine with diffuse wall thickening, findings consistent with the hypoperfusion complex. The aorta (a) is small in caliber. A large amount of free intraperitoneal fluid (F) and a large liver laceration are present. (21) Hypoperfusion complex in a 4-year-old boy after a motor vehicle accident in which he was unrestrained. In the ensuing fire, the patient suffered full-thickness burns over 90% of his body surface area. CT scan shows marked diffuse wall thickening of the small intestine. The aorta (a) and inferior vena cava (i) are small in caliber. C = air-filled colon (not free air), F = free intraperitoneal fluid. The patient died shortly after the CT study.
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Figures 20, 21. (20) Hypoperfusion complex in an 8-year-old boy after a motor vehicle accident. The patient appeared to be in stable condition on entering the CT scanner but experienced cardiac arrest during scanning (after this image was obtained) and could not be resuscitated. CT scan shows diffuse distended small intestine with diffuse wall thickening, findings consistent with the hypoperfusion complex. The aorta (a) is small in caliber. A large amount of free intraperitoneal fluid (F) and a large liver laceration are present. (21) Hypoperfusion complex in a 4-year-old boy after a motor vehicle accident in which he was unrestrained. In the ensuing fire, the patient suffered full-thickness burns over 90% of his body surface area. CT scan shows marked diffuse wall thickening of the small intestine. The aorta (a) and inferior vena cava (i) are small in caliber. C = air-filled colon (not free air), F = free intraperitoneal fluid. The patient died shortly after the CT study.
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Copyright © 1999 by the Radiological Society of North America.
