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Detecting Blunt Intestinal Injury Is Still Difficult Despite Newer Scanners

March 30, 2009
Written by: , Filed in: Emergency Radiology
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While solid organ injury is easy to diagnose with CT scan, blunt bowel and mesenteric injuries remain problematic.

A recent retrospective review of prospectively collected data set out to determine if multi-slice CT scanning has reduced the incidence of missed bowel and mesenteric injuries in patients with blunt abdominal trauma.

The results, published in The Journal of Trauma®, conclude that diagnosing blunt bowel and mesenteric injuries continues to be difficult, even with newer CT scanners.

The Study
82 patients with blunt bowel and mesenteric injuries were identified from a total of 10,506 blunt trauma admissions recorded in a trauma registry. Fifty-seven of these patients had CT imaging before going to the operating room.

A timely laparotomy was performed on 46 of 57 patients within 8 hours of arrival. No specific CT findings were defined indicating blunt bowel or mesenteric injury.

Negative CT scans were stratified into 2 groups based on using a 4- or 16-slice scanner. Primary end point was accuracy of CT scanning in identifying blunt bowel and mesenteric injuries. Secondary end point was a comparison of the 2 scanners.

The scanning technique used 7.5-mm sections and IV contrast.

46 patients (81%) had CT scans showing a bowel or mesenteric injury.

CT findings included:

  • free fluid without solid organ injury (51%)
  • pneumoperitoneum (11%)
  • active mesenteric bleeding (11%)
  • bowel swelling (5%).

CT scan sensitivity was 86%. Eleven patients had CT scans that were interpreted as negative; 3 of these had small amounts of intraperitoneal fluid without a solid organ injury and 8 scans were read as normal.

Six of these 8 had a repeat CT scan between 12 hours and 6 days later showing positive findings.

Two patients had a laparotomy secondary to clinical deterioration.

False-negative scans occurred in 8 of 40 patients (20%) with the 4-slice scanner, and in 3 of 17 (18%) with the 16-slice scanner.

Diagnosis of blunt bowel and mesenteric injuries continues to be difficult, even with newer CT scanners.

Reviewer’s Comments
This study is small and uses a scanning technique that might not be adequate to detect this type of injury. We currently scan at 5-mm sections through the abdomen and 2.5 mm through the pelvis. We also are using a 32- or 64-slice scanner, which gives us excellent detail.

We believe that free fluid without solid organ injury is the primary finding in the majority of these patients.

Free fluid that is seen in over 3 cm or in multiple places is used to indicate an injury.

Pneumoperitoneum is often very subtle.

Mesenteric streaking as well as bowel swelling or mucosal thickening are also positive findings.

We believe blunt bowel and mesenteric injuries can be diagnosed with current CT technology and a vigilant trauma team. A missed bowel injury does increase morbidity, and induces possible mortality, and should be placed on the list of preventable missed injuries for most Level 1 trauma centers.

Author: John A. Weigelt, MD

Ekeh AP, Saxe J, et al. Diagnosis of Blunt Intestinal and Mesenteric Injury in the Era of Multidetector CT Technology–Are Results Better?

J Trauma; 2008;65 (August): 354-359

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