CT of Blunt Trauma Bowel and Mesenteric Injury: Typical Findings and Pitfalls in Diagnosis1
Jeffrey M. Brody, MD ,
Danielle B. Leighton, MD ,
Brian L. Murphy, MD ,
Gerald F. Abbott, MD ,
Jonathan P. Vaccaro, MD ,
Liudvikas Jagminas, MD and
William G. Cioffi, MD
1 From the Departments of Diagnostic Imaging (J.M.B., D.B.L., B.L.M., G.F.A., J.P.V.), Emergency Medicine (L.J.), and Surgery (W.G.C.), Brown University School of Medicine, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903. Recipient of a Certificate of Merit award for a scientific exhibit at the 1999 RSNA scientific assembly. Received March 27, 2000; revision requested April 25 and received June 28; accepted July 6. Address correspondence to J.M.B. (e-mail: jbrody@lifespan.org).
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Figure 1a. Duodenal and jejunal perforations in a 65-year-old woman. (a) Abdominal CT scan reveals free fluid (black arrow), free intraperitoneal air (white arrowhead), retroperitoneal air (black arrowhead), and intraperitoneal contrast material (white arrow). (b) On a CT scan obtained at a lower level, a large quantity of free contrast material outlines a pelvic small-bowel loop (white arrows).
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Figure 1b. Duodenal and jejunal perforations in a 65-year-old woman. (a) Abdominal CT scan reveals free fluid (black arrow), free intraperitoneal air (white arrowhead), retroperitoneal air (black arrowhead), and intraperitoneal contrast material (white arrow). (b) On a CT scan obtained at a lower level, a large quantity of free contrast material outlines a pelvic small-bowel loop (white arrows).
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Figure 2a. Perforation of the duodenal "C" loop in a 17-year-old girl. (a) Abdominal CT scan shows a thick-walled duodenum (arrow), outlined by extraluminal retroperitoneal air (arrowheads). (b) CT scan of the pelvis reveals foci of retroperitoneal air that have escaped from the duodenal perforation (arrowhead).
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Figure 2b. Perforation of the duodenal "C" loop in a 17-year-old girl. (a) Abdominal CT scan shows a thick-walled duodenum (arrow), outlined by extraluminal retroperitoneal air (arrowheads). (b) CT scan of the pelvis reveals foci of retroperitoneal air that have escaped from the duodenal perforation (arrowhead).
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Figure 3a. Extraperitoneal bladder rupture and normal bowel loops in a 77-year-old woman. (a) CT cystogram obtained after retrograde filling of the bladder shows an intravesicle air-contrast level (black arrow) and contrast material in the perivesicle extraperitoneal space (white arrows). (b) On a CT image obtained at a higher level, abdominal wall motion artifact blurs the outline of a small focus of air in the preperitoneal space (arrow). The air was introduced during retrograde bladder filling and mimics free intraperitoneal air.
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Figure 3b. Extraperitoneal bladder rupture and normal bowel loops in a 77-year-old woman. (a) CT cystogram obtained after retrograde filling of the bladder shows an intravesicle air-contrast level (black arrow) and contrast material in the perivesicle extraperitoneal space (white arrows). (b) On a CT image obtained at a higher level, abdominal wall motion artifact blurs the outline of a small focus of air in the preperitoneal space (arrow). The air was introduced during retrograde bladder filling and mimics free intraperitoneal air.
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Figure 4a. Proximal ileum perforation and mesenteric hematoma in a 41-year-old man. (a) Abdominal CT scan demonstrates intramural air in the ileum (solid arrow) and adjacent interloop free fluid (open arrows). (b) CT scan obtained at a lower level shows mucosal enhancement (arrowhead) of a more distal ileal segment.
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Figure 4b. Proximal ileum perforation and mesenteric hematoma in a 41-year-old man. (a) Abdominal CT scan demonstrates intramural air in the ileum (solid arrow) and adjacent interloop free fluid (open arrows). (b) CT scan obtained at a lower level shows mucosal enhancement (arrowhead) of a more distal ileal segment.
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Figure 5. A 10-cm-long jejunal laceration and mesenteric avulsion of the descending colon in a 35-year-old man. CT scan demonstrates thick-walled jejunal loops (black arrows), hemoperitoneum (arrowhead), and free intraperitoneal contrast material (white arrows).
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Figure 6a. Midjejunal partial thickness tear but normal liver and spleen in a 20-year-old man. (a) Abdominal CT scan shows hemoperitoneum surrounding the intact liver capsule (arrowheads). (b) CT scan obtained at a lower level reveals interloop fluid (solid arrow) and mesenteric stranding (open arrow) in the absence of bowel-wall thickening, findings that are more suggestive of mesenteric injury than of parenchymal organ damage.
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Figure 6b. Midjejunal partial thickness tear but normal liver and spleen in a 20-year-old man. (a) Abdominal CT scan shows hemoperitoneum surrounding the intact liver capsule (arrowheads). (b) CT scan obtained at a lower level reveals interloop fluid (solid arrow) and mesenteric stranding (open arrow) in the absence of bowel-wall thickening, findings that are more suggestive of mesenteric injury than of parenchymal organ damage.
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Figure 7. Middle colic artery laceration in a 38-year-old man. CT scan shows a lobulated hyperattenuating area (arrow) that represents extravasation of contrast material within an otherwise nonopacified hematoma (arrowheads).
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Figure 8a. Splenic and mesenteric lacerations in a 41-year-old man. (a) Abdominal CT scan reveals a splenic laceration (arrow), which contributed to hemoperitoneum (arrowheads). (b) CT scan obtained at a lower level shows a focus of contrast material extravasation (arrow) and adjacent stranding, findings that help identify the mesenteric laceration. (Note: A low rate of intravenous administration of contrast material results in faint attenuation of the contrast material extravasation.) Adjacent interloop fluid (arrowhead) is present.
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Figure 8b. Splenic and mesenteric lacerations in a 41-year-old man. (a) Abdominal CT scan reveals a splenic laceration (arrow), which contributed to hemoperitoneum (arrowheads). (b) CT scan obtained at a lower level shows a focus of contrast material extravasation (arrow) and adjacent stranding, findings that help identify the mesenteric laceration. (Note: A low rate of intravenous administration of contrast material results in faint attenuation of the contrast material extravasation.) Adjacent interloop fluid (arrowhead) is present.
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Figure 9. Duodenal and pancreatic contusions with adjacent hematoma in a 36-year-old woman. CT scan shows a thick-walled duodenum (black arrows) with surrounding blood (white arrow) and additional blood surrounding mesenteric vessels (arrowhead). No free air is seen. The pancreas appeared normal on other CT images (not shown).
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Figure 10a. Multiple mesenteric tears in a 75-year-old woman. Abdominal CT scan (a) shows a liver laceration (black arrow). This injury was erroneously thought to be the cause of layering hemoperitoneum outlining the uterus (white arrows), seen on a CT scan of the pelvis (b). Subsequent laparotomy demonstrated an intact liver capsule with mesenteric lacerations as the bleeding source. CT scans obtained through the mesentery were normal (not shown).
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Figure 10b. Multiple mesenteric tears in a 75-year-old woman. Abdominal CT scan (a) shows a liver laceration (black arrow). This injury was erroneously thought to be the cause of layering hemoperitoneum outlining the uterus (white arrows), seen on a CT scan of the pelvis (b). Subsequent laparotomy demonstrated an intact liver capsule with mesenteric lacerations as the bleeding source. CT scans obtained through the mesentery were normal (not shown).
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Figure 11. Intraperitoneal bladder rupture and mesenteric lacerations in a 29-year-old man. CT scan demonstrates free contrast material (black arrows) from an intraperitoneal bladder rupture that masks evidence of mesenteric bleeding. Contrast material extends into the subcutaneous tissue (white arrows) through a rupture at the origin of the oblique muscles.
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Figure 12a. Contusion of the second portion of the duodenum, right adrenal hematoma, and intraparenchymal liver laceration in a 36-year-old man. (a) Abdominal CT scan demonstrates an intraparenchymal liver laceration (white arrow) and adrenal hematoma (black arrow), with surrounding retroperitoneal blood (arrowhead). (b) On a CT scan obtained at a lower level, periduodenal hematoma thought to be from the other injuries masks the duodenal injury (arrows), which could be suspected on the basis of its ill-defined wall and adjacent blood.
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Figure 12b. Contusion of the second portion of the duodenum, right adrenal hematoma, and intraparenchymal liver laceration in a 36-year-old man. (a) Abdominal CT scan demonstrates an intraparenchymal liver laceration (white arrow) and adrenal hematoma (black arrow), with surrounding retroperitoneal blood (arrowhead). (b) On a CT scan obtained at a lower level, periduodenal hematoma thought to be from the other injuries masks the duodenal injury (arrows), which could be suspected on the basis of its ill-defined wall and adjacent blood.
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Figure 13a. Transection of the second portion of the duodenum and full-thickness perforation of the right colon in a 46-year-old woman. (a) Abdominal CT scan reveals a thick-walled and ill-defined duodenum (straight arrows) and free and retroperitoneal air (curved arrows), findings that suggest duodenal injury. (b) Another CT scan obtained at a lower level shows air and fluid (open arrows) adjacent to the right colon. These findings were thought to be associated with the duodenal injury because both the duodenum and right colon reside in the anterior pararenal space. Black arrow indicates free air. The thick-walled jejunum (solid white arrow) was normal at surgery.
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Figure 13b. Transection of the second portion of the duodenum and full-thickness perforation of the right colon in a 46-year-old woman. (a) Abdominal CT scan reveals a thick-walled and ill-defined duodenum (straight arrows) and free and retroperitoneal air (curved arrows), findings that suggest duodenal injury. (b) Another CT scan obtained at a lower level shows air and fluid (open arrows) adjacent to the right colon. These findings were thought to be associated with the duodenal injury because both the duodenum and right colon reside in the anterior pararenal space. Black arrow indicates free air. The thick-walled jejunum (solid white arrow) was normal at surgery.
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Figure 14a. Distal jejunal perforation, mesenteric hematoma, and liver laceration in a 51-year-old woman. (a) Abdominal CT scan shows a large liver laceration (arrow) with hemoperitoneum (arrowhead). (b) On a CT scan obtained at a lower level, subtle collections of intramural air (black arrow) and intraperitoneal air (white arrows) in the region of the thick-walled jejunum were not appreciated.
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Figure 14b. Distal jejunal perforation, mesenteric hematoma, and liver laceration in a 51-year-old woman. (a) Abdominal CT scan shows a large liver laceration (arrow) with hemoperitoneum (arrowhead). (b) On a CT scan obtained at a lower level, subtle collections of intramural air (black arrow) and intraperitoneal air (white arrows) in the region of the thick-walled jejunum were not appreciated.
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Figure 15a. Right diaphragmatic rupture and duodenal contusion in a 43-year-old man. (a) Abdominal CT scan shows a posterior right rib fracture (arrow) at the site of a diaphragmatic hematoma (black arrowheads). (b) On a CT scan obtained at a lower level, extension of the diaphragmatic hematoma into the posterior pararenal space (arrow) was erroneously thought to be the source of the periduodenal hematoma in the anterior pararenal space. Subcutaneous air (white arrowheads in a and b) from barotrauma is visible.
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Figure 15b. Right diaphragmatic rupture and duodenal contusion in a 43-year-old man. (a) Abdominal CT scan shows a posterior right rib fracture (arrow) at the site of a diaphragmatic hematoma (black arrowheads). (b) On a CT scan obtained at a lower level, extension of the diaphragmatic hematoma into the posterior pararenal space (arrow) was erroneously thought to be the source of the periduodenal hematoma in the anterior pararenal space. Subcutaneous air (white arrowheads in a and b) from barotrauma is visible.
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Figure 16. Multiple mesenteric and serosal jejunal tears in a 43-year-old man. CT scan shows thick-walled small-bowel loops (open arrows) that are partially obscured by an extraneous artifact (solid white arrows). The retroperitoneal hematoma (black arrows) is related to a renal laceration (not shown). Air between the internal and external oblique muscles (arrowhead) is related to barotrauma.
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Copyright © 2000 by the Radiological Society of North America.
