Hospital: HOSPITAL GENERAL DE VALENCIA, ASCIRES(ERESA, HOSPITAL GENERAL DE VALENCIA), Hospital Universitario
Aut@r o Autores: J. Rivera Mata, M. Shahin, C. Sepmere Ortega.
A 56-year-old patient is referred to the emergency room after blunt trauma during highweight chest crushing. The patient was hemodynamically unstable, with hypotension, tachycardia and silence in left hemithorax auscultation. Intubation was necessary. The CT showed rupture of the anterior margin of the diaphragm with migration of mesenteric fat, stomach, small intestine and colon to the chest. Lower left lobe atelectasia. At the abdomen level there were haemoperitoneum, fat stranding and accumulation of free contrast on the venous phase inside the abdominal cavity. Pneumoperitoneum. All findings were confirmed in urgent surgery.
A large number of complications are likely in the context of blunt trauma, one of which is diaphragmatic rupture and mesenteric injury(1,2). The bowel and mesentery are injured in range 0.3-5% of blunt force abdominal trauma. On the other hand the estimated incidence of diaphragmatic rupture is ~4.5% (3). The left hemidiaphragm is involved three times more frequently than the right. The most common site of rupture is the posterolateral aspect of the hemidiaphragm. The most commonly-herniated viscera are the stomach and colon. Direct discontinuity of the hemidiaphragm may be seen with or without intrathoracic herniation of abdominal contents. Other signs of diaphragmatic rupture include (3): - The collarsign and the dependent viscera sign. - Segmental non-recognition of the diaphragm. - Focal diaphragmatic thickening. - Thoracic fluid abutting the abdominal viscera. - hemothorax (indirect features ). Mesenteric injuries can include active bleeding and mesenteric hematoma (1,3). - definitive signs: o Active extravasation of contrast media. o intermesenteric free fluid. o Abrupt termination of the mesenteric vessels. o Accumulation ('pooling') of contrast on multiphase imaging. - Suggestive signs. o Haziness and fat stranding. o Mesenteric hematoma. o Bowel wall thickening.
Closed abdominal trauma is associated with specific and infrequent injuries that compromise the patient's life and prognosis. Radiologist should identify their direct and indirect signs. The realization of the adequate protocol facilitates the diagnosis of mesenteric lesions. When multiphase study is performed arterial and venous bleeding can be identified.
- Jeffrey M. Brody, MD Danielle B. Leighton, MD Brian L. Murphy, MD Gerald F. Abbott, MD Jonathan P. Vaccaro, MD Liudvikas Jagminas, MD William G. Cioffi, MD. CT of Blunt Trauma Bowel and Mesenteric Injury: Typical Findings and Pitfalls in Diagnosis. R