British Journal of Radiology (2007) 80, 143-145
© 2007 British Institute of Radiology
doi: 10.1259/bjr/31246443
Abdominal distension 3 days post-high-speed road traffic accident
J M Hanson, FFRRCSI, FRCR
and
E B Hayeems, MD, FRCR
Department of Medical Imaging, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
Correspondence: Dr John Hanson, Department of Radiology, Our Lady of Lourdes Hospital, Progheda, Co. Louth, Ireland. E-mail: john.hanson{at}maile.hse.ie
 |
Introduction
|
|---|
A 38-year-old female suffered a closed head injury and compound pelvic fracture after a high-speed motor vehicle accident. The CT scan on admission revealed unstable compound pelvic fractures, which included a right lateral sacral, bilateral pubic rami and a left sided non-displaced acetabular fracture (
Figures 1–2). She had a trace amount of free intraperitoneal fluid. The CT was otherwise considered unremarkable for a solid or hollow visceral injury. Owing to the severity of her head injury, the pelvic fractures were treated conservatively. Over the ensuing days she demonstrated signs of obstruction and, at day 3, a repeat CT for her nausea and abdominal distension was performed (Figure 3) with a working diagnosis of an adynamic ileus.
What is the diagnosis?
|
Diagnosis and discussion
|
|---|
High-grade small bowel obstruction due to bowel entrapment in the sacral fracture.
The abdominal plain film and CT scan showed a high-grade small bowel obstruction (
Figures 3–5). This was due to small bowel entrapment. She required a laparotomy to free the entrapped bowel loop from the sacral fractured segment. This was complicated by two small perforations during the mobilization of the entrapped segment and a further serosal tear, all of which were treated with transverse stapling.
View larger version (88K):
[in this window]
[in a new window]
|
Figure 4. Axial CT image showing numerous dilated small bowel loops and free intraperitoneal fluid(arrows).
|
|
View larger version (88K):
[in this window]
[in a new window]
|
Figure 5. Axial CT image showing the right sacral fracture and the entrapped bowel segment(arrows). Note the angulation of the dilated segment and the adjacent fluid, haematoma in the region of the fracture.
|
|
The patient's bowel function returned rapidly. Her hospital stay was further complicated by the acetablar fracture displacing, which required delayed fixation. She was discharged to rehabilitation after 5 weeks acute hospitalization.
Numerous studies have demonstrated the associations of blunt visceral injuries associated with pelvic trauma. Bowel entrapment complicating skeletal fractures has not been documented in these studies [1–3].
Post-traumatic bowel entrapment was first described in 1907 [4]. Since then there have only been occasional reports in the literature. Stubbard et al, in a review of the literature, have documented 19 such cases [5]. Five of these 19 died because of sepsis. The diagnosis of entrapment is often difficult and delayed. As with our case, most cases of distension and nausea post-pelvic fracture are thought to be due to an adynamic ileus and not that of a mechanical obstruction. An adynamic ileus complicates as many as 18% of pelvic fractures [5]. The cause for the ileus is due to retroperitoneal haematoma. Hurt et al stated that such an ileus usually lasts 5 days, but can persist longer than 2 weeks [6]. This can lull the attending Physician into a false sense of security. Owing to the morbidity and mortality associated with an entrapped segment, one should always be aware of such a complication.
With the introduction of multidetector CT and the associated reformatting capabilities, the diagnosis of this complication should be made more accurately. On retrospect, tethering of small bowel loops was noted in the region of the sacral fracture on our initial study (Figure 2). In conclusion, clinicians and radiologists should be aware of this potentially lethal complication of pelvic fractures. Patients should be scanned earlier when there is a persisting ileus or sepsis to exclude bowel entrapment.
Received for publication July 25, 2005.
Revision received September 7, 2005.
Accepted for publication November 25, 2005.
|
References
|
|---|
- Peltier LF. Complications associated with fractures of the pelvis. J Bone Joint Surg 1965;47A:1060–9.[Abstract/Free Full Text]
- Moore JR. Pelvic fractures. Associated intestinal and mesenteric lesions. Can J Surg 1966;9:253–61.[Medline]
- Ashai F, Mam MK, Shabir I. Ileal entrapment as a complication of fractured pelvis. J Trauma 1988;28:551–2.[Medline]
- Arnold GJ. A case fracture of the pelvis from slight violence, with nipping of small intestine between the fragments causing acute intestinal obstruction and general peritonitis. Lancet 1909;27:1157–8.
- Stubbard JR, Merkley M. Bowel entrapment within pelvic fractures: a case report and review of the literature. J Orthop Trauma 1999;13:145–8.[CrossRef][Medline]
- Hurt AV, Ochsner JL, Schiller WR. Prolonged ileus after severe pelvic fracture. Am J Surg 1983;146:755–7.[CrossRef][Medline]
Top
Introduction
Diagnosis and discussion
