British Journal of Radiology 74 (2001),277-279 © 2001 The British Institute of Radiology
Ischaemic ileal stenosis following blunt abdominal trauma and demonstrated by CT
Y Tsushima, MD1,
S Yamada, MD2,
J Aoki, MD3 and
K Endo, MD3
1 Departments of Radiology
2 Surgery, Motojima General Hospital, 3-8 Nishi-honcho, Ohta, Gunma, 373-0033
3 Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-0034 Japan
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Abstract
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We report a case of blunt abdominal trauma in which delayed ischaemic ileal stenosis occurred. A 24-year-old man presented with symptoms and signs of bowel obstruction 2 weeks after blunt abdominal trauma. Enhanced CT clearly demonstrated a stenotic ileal loop with mural thickening, associated with a mesenteric haematoma. This abnormal ileal loop was resected.
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Introduction
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Damage to intestine by blunt abdominal trauma is usually evident within hours or days after the accident. However, post-traumatic intestinal stenosis is characterized by a delayed onset of obstructive symptoms and diagnosis is often difficult [1–8]. We report a case of post-traumatic ischaemic stenosis of the ileum, associated with mesenteric haematoma, in which CT was useful in establishing the diagnosis.
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Case report
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A 24-year-old man was admitted to hospital complaining of chest and upper abdominal pain after his abdomen was injured by a forklift. He was alert and haemodynamically stable. On examination there was tenderness in the epigastrium and right hypochondrium. Bowel sounds were normal. Unenhanced CT of the chest and upper abdomen showed a small amount of pleural fluid on the right side, suggesting mild haemothorax and lung contusion, although the upper abdomen was unremarkable except for a slightly fatty liver. CT of the lower abdomen was not performed at this time as there was no clinical suspicion of lower abdominal injury. The patient improved rapidly with conservative treatment and demonstrated normal intestinal function. He was discharged 11 days after admission.
4 days after discharge the patient returned to hospital complaining of abdominal pain and nausea. His abdomen was distended, but clinical examination did not demonstrate any abdominal masses or tenderness. A plain radiograph of the abdomen showed dilated small bowel loops with air–fluid levels, consistent with intestinal obstruction. He improved on conservative treatment with nasogastric suction and intravenous fluid replacement. However, after ingesting a small amount of food he again complained of abdominal pain and plain radiography once more showed mechanical small bowel obstruction. Enhanced CT of the abdomen using a bolus injection technique (Figure 1
) showed an ileal loop with a thickened wall and narrow lumen. A mass lesion was also demonstrated in the adjacent mesentery, consistent with subacute haematoma.
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Figure 1. Contrast enhanced CT of the abdomen performed 18 days after blunt abdominal trauma. There is an abnormal ileal loop (arrows) with mural thickening, well enhanced mucosa and narrowing of its lumen. *Subacute haematoma of the mesentery. **Dilated proximal small bowel.
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A stenotic ileal loop, 150 cm from the terminal ileum, was found on laparotomy. The wall of this loop was thickened, had brown discoloration and was associated with a small haematoma in the adjacent mesentery (Figure 2). There was no evidence of perforation. The abnormal ileal loop, which was 40 cm in length, was resected, and post-operative recovery was uneventful. Histological examination showed ischaemic and fibrotic changes within the ileal wall. 6 months post-operatively the patient remained in good health.
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Figure 2. Photograph of the resected ileum. The small intestine (arrows) is stenotic and fibrotic. There is a subacute haematoma (*) due to mesenteric injury, parallel to the involved ileum.
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Discussion
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Intestinal and mesenteric injuries are found in approximately 5% of all patients undergoing laparotomy after blunt abdominal trauma [9, 10], but post-traumatic intestinal stenosis due to blunt abdominal trauma is very rare [1–8]. Patients with this condition characteristically have a delayed onset of obstructive symptoms as in this case, and diagnosis is often difficult [1–8]. Small bowel barium infusion (enteroclysis) is considered the best technique for demonstrating lesions of the small intestine [1, 3, 5], and may show a narrowed intestinal lumen.
Contrast enhanced CT should be performed early in patients with blunt abdominal trauma because most significant bowel and mesenteric injuries, as well as associated injuries to other abdominal viscera, are reliably identified by CT [9–11]. CT is also the most appropriate first investigation in suspected bowel obstruction, as not only does it confirm the presence of obstruction but also often shows the cause [12–14]. Nevertheless, there has been only one reported case of post-traumatic intestinal stenosis demonstrated by CT [4], with partial small bowel obstruction and mural thickening. In our case, the stenotic ileal loop with its thickened wall was clearly demonstrated on enhanced CT. These two cases suggest that CT is the appropriate imaging modality when there is the clinical suspicion of a post-traumatic intestinal stenosis. Although angiography may show mesenteric vessel occlusion and may provide additional information concerning mesenteric injury [4], contrast enhanced CT may provide sufficient information to define the appropriate treatment plan.
Taylor [8], reviewing the pathological findings of post-traumatic intestinal stenosis, reported that the majority of lacerations occurred parallel and close to the involved intestine. Bryner et al [2] suggested that the stenosis is due entirely to infarction resulting from mesenteric vascular damage rather than direct injury to the intestine. In our case, there was a mesenteric haematoma parallel to the involved ileum, although the mesenteric vascular damage was not directly confirmed at laparotomy.
Patients with blunt abdominal trauma are often managed without surgical intervention if there are no signs of bowel perforation or hypovolaemic shock. Post-traumatic intestinal stenosis should be considered if a patient returns to hospital several days or weeks after blunt abdominal trauma with symptoms or signs of bowel obstruction. Contrast enhanced CT of the whole abdomen should then be the first investigation.
Received for publication August 15, 2000.
Revision received October 31, 2000.
Accepted for publication November 27, 2000.
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References
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Abstract
Introduction
