Ischaemic ileal stenosis following blunt abdominal trauma and

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Ischaemic ileal stenosis following blunt abdominal trauma and Powered By Docstoc
					The British Journal of Radiology, 74 (2001), 277–279     E   2001 The British Institute of Radiology

Case report
Ischaemic ileal stenosis following blunt abdominal
trauma and demonstrated by CT
Departments of 1Radiology and 2Surgery, Motojima General Hospital, 3-8 Nishi-honcho, Ohta, Gunma
373-0033 and 3Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Hospital,
3-39-15 Showa-machi, Maebashi, Gunma 371-0034, Japan

    Abstract. 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

   Damage to intestine by blunt abdominal                      air–fluid levels, consistent with intestinal obstruc-
trauma is usually evident within hours or days                 tion. He improved on conservative treatment with
after the accident. However, post-traumatic                    nasogastric suction and intravenous fluid replace-
intestinal stenosis is characterized by a delayed              ment. However, after ingesting a small amount of
onset of obstructive symptoms and diagnosis is                 food he again complained of abdominal pain and
often difficult [1–8]. We report a case of post-                plain radiography once more showed mechanical
traumatic ischaemic stenosis of the ileum, asso-               small bowel obstruction. Enhanced CT of the
ciated with mesenteric haematoma, in which CT                  abdomen using a bolus injection technique
was useful in establishing the diagnosis.                      (Figure 1) showed an ileal loop with a thickened
                                                               wall and narrow lumen. A mass lesion was also
                                                               demonstrated in the adjacent mesentery, consis-
Case report                                                    tent with subacute haematoma.
   A 24-year-old man was admitted to hospital                     A stenotic ileal loop, 150 cm from the terminal
complaining of chest and upper abdominal pain                  ileum, was found on laparotomy. The wall of this
after his abdomen was injured by a forklift. He                loop was thickened, had brown discoloration and
was alert and haemodynamically stable. On                      was associated with a small haematoma in the
examination there was tenderness in the epigas-                adjacent mesentery (Figure 2). There was no
trium and right hypochondrium. Bowel sounds                    evidence of perforation. The abnormal ileal
were normal. Unenhanced CT of the chest and
upper abdomen showed a small amount of pleural
fluid on the right side, suggesting mild hae-
mothorax 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
                                                               Figure 1. Contrast enhanced CT of the abdomen
masses or tenderness. A plain radiograph of the                performed 18 days after blunt abdominal trauma.
abdomen showed dilated small bowel loops with                  There is an abnormal ileal loop (arrows) with mural
                                                               thickening, well enhanced mucosa and narrowing of
Received 15 August 2000 and in revised form 31 October         its lumen. *Subacute haematoma of the mesentery.
2000, accepted 27 November 2000.                               **Dilated proximal small bowel.

The British Journal of Radiology, March 2001                                                                   277
                                                                   Y Tsushima, S Yamada, J Aoki and K Endo

                                                         angiography may show mesenteric vessel occlu-
                                                         sion 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
Figure 2. Photograph of the resected ileum. The small    confirmed at laparotomy.
intestine (arrows) is stenotic and fibrotic. There is a      Patients with blunt abdominal trauma are often
subacute haematoma (*) due to mesenteric injury,         managed without surgical intervention if there are
parallel to the involved ileum.                          no signs of bowel perforation or hypovolaemic
                                                         shock. Post-traumatic intestinal stenosis should be
loop, which was 40 cm in length, was resected,           considered if a patient returns to hospital several
and post-operative recovery was uneventful.              days or weeks after blunt abdominal trauma with
Histological examination showed ischaemic and            symptoms or signs of bowel obstruction. Contrast
fibrotic changes within the ileal wall. 6 months          enhanced CT of the whole abdomen should then
post-operatively the patient remained in good            be the first investigation.

Discussion                                                1. Isaacs P, Rendall M, Hoskins EOL, Missen GAK,
                                                             Sladen GE. Ischemic jejunal stenosis and blind loop
   Intestinal and mesenteric injuries are found in           syndrome after blunt abdominal trauma. J Clin
approximately 5% of all patients undergoing                  Gastroenterol 1987;9:96–8.
laparotomy after blunt abdominal trauma                   2. Bryner UM, Longerbeam JK, Reeves CD. Post-
[9, 10], but post-traumatic intestinal stenosis due          traumatic ischemic stenosis of the small bowel. Arch
to blunt abdominal trauma is very rare [1–8].                Surg 1980;115:1039–41.
                                                          3. Marks CG, Nolan DJ, Piris J, Webster CU. Small
Patients with this condition characteristically have         bowel strictures after blunt abdominal trauma. Br
a delayed onset of obstructive symptoms as in this           J Surg 1979;66:663–4.
case, and diagnosis is often difficult [1–8]. Small        4. De Backer AI, De Schepper AMA, Vaneerdeweg
bowel barium infusion (enteroclysis) is considered           W, Pelckmans P. Intestinal stenosis from mesenteric
the best technique for demonstrating lesions of              injury after blunt abdominal trauma. Eur Radiol
the small intestine [1, 3, 5], and may show a             5. Hirota C, Iida M, Aoyagi K, Matsumoto T, Yao T,
narrowed intestinal lumen.                                   Fujishima M. Post-traumatic intestinal stenosis:
   Contrast enhanced CT should be performed                  clinical and radiographic features in four patients.
early in patients with blunt abdominal trauma                Radiology 1995;194:813–5.
because most significant bowel and mesenteric              6. Urban CH. Stenosis of ileum due to mesenteric
                                                             laceration. JAMA 1968;204:176–7.
injuries, as well as associated injuries to other         7. Mock HE. Infective granuloma. Surg Gynecol
abdominal viscera, are reliably identified by CT              Obstet 1931;52:672.
[9–11]. CT is also the most appropriate first              8. Taylor F. Seat-belt injury resulting in regional
investigation in suspected bowel obstruction, as             enteritis and intestinal obstruction. JAMA 1971;
not only does it confirm the presence of obstruc-             215:1154–5.
tion but also often shows the cause [12–14].              9. Rizzon MJ, Federie MP, Griffiths BG. Bowel
                                                             and mesenteric injury following blunt abdominal
Nevertheless, there has been only one reported               trauma: evaluation with CT. Radiology 1989;173:
case of post-traumatic intestinal stenosis demon-            143–8.
strated by CT [4], with partial small bowel              10. Ngheim HV, Jeffrey RB Jr, Mindelzun RE. CT of
obstruction and mural thickening. In our case,               blunt trauma to the bowel and mesentery. AJR
the stenotic ileal loop with its thickened wall was          1993;160:53–8.
                                                         11. Becker CD, Mentha G, Schmidlin F, Terrier F.
clearly demonstrated on enhanced CT. These two
                                                             Blunt abdominal trauma in adults: role of CT in the
cases suggest that CT is the appropriate imaging             diagnosis and management of visceral injuries. Part
modality when there is the clinical suspicion                2: gastrointestinal tract and retroperitoneal organs.
of a post-traumatic intestinal stenosis. Although            Eur Radiol 1998;8:772–80.

278                                                               The British Journal of Radiology, March 2001
Case report: Post-traumatic ischaemic ileal stenosis

12. Ha HK, Shin BS, Lee SI, Yoon KH, Yook JH,             14. Suri S, Gupta S, Sudhakar PJ, Venkataramu NK,
    Rha SE, et al. Usefulness of CT in patients               Sood B, Wig JD. Comparative evaluation of plain
    with intestinal obstruction who have undergone            films, ultrasound and CT in the diagnosis of
    abdominal surgery for malignancy. AJR 1998;171:           intestinal obstruction. Acta Radiol 1999;40:422–8.
13. Peck JJ, Milleson T, Phelan J. The role of computed
    tomography with contrast and small bowel follow-
    through in management of small bowel obstruction.
    Am J Surg 1999;177:375–8.

The British Journal of Radiology, March 2001                                                                279