IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):376–379.www.ijcasereportsandimages.com

Missed mesenteric injury in blunt abdominal trauma:A potentially lethal errorVictor Kong, John Burce, George Oosthuizen, Grant Laing,Damian Clarke

ABSTRACTIntroduction: Mesenteric injury following bluntabdominal trauma is uncommon. Delay indiagnosis is unfortunately common due to itssubtle clinical presentation and is associatedwith significant morbidity and mortality. CaseReport: We present a case of a 35­year­old malewho was discharged home with a missedmesenteric injury. The initial computedtomography scan of the abdomen and pelvis wasnormal. He re­presented acutely with smallbowel infarction. Conclusion: Althoughcomputed tomography is the current goldstandard of investigation, a very smallproportion of injuries that require surgicalintervention will invariably be missed. This casehighlights several pitfalls in evaluation of thesepatients. Clinicians must always be vigilant ofsuch injury despite normal radiological studies.A sufficient period of observation post injuryshould be considered in circumstances where

the possibility of mesenteric injury is increased.Such circumstances include lack of seat beltusage, high­speed impact and decelerationinjury.Keywords: Mesentery, Trauma, Missed injuries,Blunt

*********Kong V, Burce J, Oosthuizen G, Laing G, Clarke D.Missed mesenteric injury in blunt abdominal trauma: Apotentially lethal error. International Journal of CaseReports and Images 2013;4(7):376–379.

*********doi:10.5348/ijcri­2013­07­335­9

INTRODUCTIONMesenteric injury following blunt abdominal traumais uncommon and the diagnosis is particularly difficultas clinical presentation is often subtle [1, 2]. Althoughcomputed tomography (CT) scan of the abdomen is themethod of choice for the evaluation of these patients, ina very small proportion of cases, the diagnosis caninvariably be missed and could potentially lead todisastrous outcome [3]. We present a case of massivemesenteric disruption complicated by small bowelinfarction in a 35­year­old male who had subtle clinicalsigns and normal CT scan of the abdomen on initialevaluation.

CASE REPORTA 35­year­old male was presented to our trauma unitfollowing a motor vehicle accident. He was the driver(unrestrained) of a mini­vehicle traveling at high speed,when it collided with a power post. The vehicle

CASE REPORT OPEN ACCESS

Victor Kong1 , John Burce2, George Oosthuizen3, GrantLaing2, Damian Clarke3

Affi l iations: 1MBChB, Surgical Registrar, PietermaritzburgMetropolitan Trauma Service, Department of Surgery,Edendale Hospital, Pietermaritzburg, KwaZulu Natal, SouthAfrica; 2FCS(SA), Consultant Trauma Surgeon,Pietermaritzburg Metropolitan Trauma Service, Departmentof Surgery, Edendale Hospital, Pietermaritzburg, KwaZuluNatal, South Africa; 3FCS(SA), Senior Consultant TraumaSurgeon, Pietermaritzburg Metropolitan Trauma Service,Department of Surgery, Edendale Hospital,Pietermaritzburg, KwaZulu Natal, South Africa .Corresponding Author: Victor Yeewai Kong, Department ofSurgery, Edendale Hospital, Private Bag X509, PlessislaerPietermaritzburg, 321 6, KwaZulu Natal, South Africa; Ph:+27(0)797411 036; Fax: +27(0)333954094; Email :victorywkong@yahoo.com

Received: 21 November 201 2Accepted: 1 1 December 201 2Published: 01 July 201 3

Kong et al. 376

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):376–379.www.ijcasereportsandimages.com Kong et al. 377

sustained only moderate damage, and at the scene,ambulance staff reported that the patient appeared to bewell. He was brought into our unit for furtherassessment.On admission the patient appeared well. He wasalert, orientated and had only minor abrasions to theforehead. His glasgow coma scale was 15 and he had fullrecollection of the event. His airway was patent, withnon­tender cervical spine. His respiratory rate was14/min, heart rate was 90/min and blood pressure was135/65 mmHg. The patient reported no specificcomplaints, but it was noted that he had a slight and illdefined, generalized tenderness in his abdomen. He hadno hematuria and his emergency bedside ultrasoundwas negative. At this time, his hemoglobin was12.5 g/dL and serum lactate was 1. Cervical spine, chestand pelvic radiographs were unremarkable.The patient was given analgesia, and over the nextfour hours he was reviewed by the duty junior traumaresident (year one resident, in the first month of therotation), by which time the patient's abdominaldiscomfort had almost subsided. The patient remainedhemodynamically stable, and he had no furthercomplaints. However, based on the mechanism ofinjury, and the concern of the possibility of occult intra­abdominal organ injury, an urgent double contrast (oraland intravenous) done CT scan of the abdomen was (64slice multi­detector). The scan was reviewed by the dutyradiologist and was reported as normal. He waseventually discharged from the unit 24 hours from thetime of his initial injury.Unfortunately, 48 hours after being discharged, thepatient represented with nausea, vomiting and aprogressively increasing amount of abdominal pain. Onarrival, he was in distress, and was diaphoretic, with arespiratory rate 40/min, heart rate 120/min, and bloodpressure 125/70 mmHg. His abdomen was grosslydistended (Figure 1), and he had generalized peritonitis.His hemoglobin 11 g/dL, and serum lactate was 7.5. Anerect chest radiograph showed no pneumoperitonium.

The original CT scan was reviewed by two seniorradiologists, both of whom reported no abnormalities.An emergency laparotomy was performed.Approximately 500 mL of clotted blood was noted onentry into the abdominal cavity. A massive small bowelmesenteric defect, with no active hemorrhage was found(Figure 2). A 20­cm segment of devascularized, dilatedand necrotic small bowel was noted (100 cm from theduodenal jejunal flexure), with evidence of imminentperforation (Figure 3). There was no other injury. Thisnecrotic portion was resected, and an end­to­endanastomosis was performed. He remained stableintraoperatively and was transferred to the generaltrauma ward. He had an uneventful recovery and wasdischarged on day­6.

Figure 1: Marked abdominal distension 48 hours afterdischarge from the trauma unit.

Figure 2: Large mesenteric defect, with devascularized smallbowel.

Figure 3: Infarcted small bowel segment with evidence ofimminent perforation.

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):376–379.www.ijcasereportsandimages.com Kong et al. 378

DISCUSSIONMesenteric injury following blunt abdominal traumais uncommon and has a reported incidence ofapproximately 1% [1–3]. One of the most commonmechanisms involves rapid deceleration, whichproduces a shearing force between fixed and mobileportions of the intestinal tract, leading to mesentericdisruption [4].This case highlights the difficulty of diagnozingmesenteric injury in blunt abdominal trauma patientsas clinical presentation is often extremely subtle. Thehistory and physical examination may be unreliable asmost patients have either minimal physical signs, orconcurrent distracting injuries. The ‘classic’ clinicaltriad of abdominal pain, rigidity and absent bowelsounds is only seen in less than one­third of all patients[5]. The delayed diagnosis of mesenteric injury isknown to be associated with significant morbidity andeven mortality [6].Multi detector computed tomography (MDCT) iscurrently the gold standard in evaluating bluntabdominal trauma in hemodynamically stable patients[3]. However, studies evaluating the diagnostic accuracyof CT in identifying mesenteric injuries have beenconflicting. Earlier studies reporting relatively lowerrate of correct identification of mesenteric injurieslargely predated MDCT. Currently, evidence frommultiple recent studies reported better diagnosticaccuracy with a sensitivity ranging from 69–95% and aspecificity of 94–100% [7].Numerous radiological signs have been described inliterature, but many are non­specific [8]. One of the keyobjectives in interpreting the CT findings in thesepatients is to establish the presence of significantmesenteric injuries that may require surgicalintervention. However, in spite of the wide availabilityof CT as part of routine trauma evaluation in thesepatients, there is likely to remain a proportion ofpatients in whom injuries can inevitably be missed. [8].Patients who are hemodynamically stable withnegative findings on CT are often admitted for repeatclinical evaluation. However, the incidence ofsignificant intra­abdominal injuries in these patients isrelatively low, and this has been reported to be less than1% of cases. [9]. Although protocols and the duration ofobservation vary between units, some have argued thatclinical observations longer than 24 hours solely toattempt identifying the small proportion of missedinjuries may not be justified. A repeat CT scan inselected patients have been advocated by some authors,but is only useful in patients with concurrent head andother multiple injuries [10].Interestingly, this patient presented with minimalabdominal pain on initial presentation, and remainedunchanged within the first 24 hours after the injury.This was possibly due to early presentation ofdisruption of the mesentery with initialdevascularization of the short bowel segment, whichproduced minimal physical findings. In our patient, thesymptoms of ischemic bowel with imminent perforation

as a sequalae of undiagnosed mesenteric injury onlypresented after 24 hours from the time of injury. Thepossibility of occult intra­abdominal injury wascorrectly entertained by the duty junior traumaresident, leading to the use of CT scan for its evaluation.The normal CT scan in this case gave an erroneousreassurance that no significant injury was sustained.Clinical decision making can be challenging,especially for the junior residents at the ‘front­line’, whoare often overwhelmed by the massive volume of majortrauma seen. Furthermore, due to severe pressure for inpatient beds (as is often the case in major trauma centerin the developing world) it may not always be possibleto admit every patient for extended period ofobservation, even if it may be justified on clinicalgrounds.Based on the severity of the mechanism of injury andthe recognition of high­risk for potential injuries, thereis a need to remain vigilent and consider extending theobservation period beyond 24 hours, even if patientsappeared ‘well’ initially. The policy of selectiveadmission, however, must be applied judiciously inhighly selected patients. Currently, without accuratepredictors to aid patient selection, this decision remainsdifficult, especially for the inexperienced.

CONCLUSIONMesenteric injury following significant abdominaltrauma is rare but carries significant morbidity as delayin recognition is common due to subtle clinicalpresentation. Although computed tomography (CT)scan is reasonably accurate in identifying such injury, itstill cannot be completely excluded by a negative scanand particularly if the computed tomography (CT) scanis carried out within a very short time frame post bluntabdominal trauma. Clinicians must always remainvigilant of the possibility of mesenteric injury and not befalsely reassured by apparently normal radiologicalfindings. Extending clinical observation periods forselected patients, based on mechanism of injury andongoing clinical suspicion, is advisable in order tominimize the chances of missing clinically significantmesenteric trauma and resultant devascularization ofsmall bowel.

*********Author ContributionsVictor Kong – Substantial contributions to conceptionand design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedJohn Burce – Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedGeorge Oosthuizen – Analysis and interpretation ofdata, Drafting the article, Revising it critically for

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):376–379.www.ijcasereportsandimages.com

important intellectual content, Final approval of theversion to be publishedGrant Laing – Analysis and interpretation of data,Drafting the article, Revising it critically for importantintellectual content, Final approval of the version to bepublishedDamian Clarke – Analysis and interpretation of data,Drafting the article, Revising it critically for importantintellectual content, Final approval of the version to bepublishedGuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© Victor Kong et al. 2013; This article is distributedunder the terms of Creative Commons Attribution 3.0License which permits unrestricted use, distributionand reproduction in any means provided the originalauthors and original publisher are properly credited.(Please see www.ijcasereportsandimages.com/copyright­policy.php for more information.)

REFERENCES1. Watts DD, Fakhry SM. Incidence of hollow viscusinjury in blunt trauma: an analysis from 275, 557trauma admissions from the East multi­institutionaltrial. J Trauma 2003;54(2):289–4.

2. Imtiaz Wani, Rayees A Bhat, Shayiq Wani, NawabKhan, Rauf A Wani, Fazal Q Parray. Isolated SmallBowel Mesentery Injury After Steering WheelTrauma. Trauma Mon 2012;17(2):279–81.3. Killeen KL, Shanmuganathan K, Poletti PA, CooperC, Mirvis SE. Helical computed tomography of boweland mesenteric injuries. J Trauma 2001Jul;51(1):26–36.4. Hughes TM, Elton C. The pathophysiology andmanagement of bowel and mesenteric injuries dueto blunt trauma. Injury 2002;33(4):295–302.5. Levine CD, Gonzales RN, Wachsberg RH, GhanekarD. CT findings of bowel and mesenteric injury. JComp Assist Tomogr 1997;21(6):974–9.6. Scaglione M, de Lutio di Castelguidone E, Scialpi M,et al. Blunt trauma to the gastrointestinal tract andmesentery: is there a role for helical CT in thedecision­ making process? Eur J Radiol2004;50(1):67–3.7. Brofman N, Atri M, Hanson JM, Grinblat L,Chughtai T, Brenneman F. Evaluation of bowel andmesenteric blunt trauma with multidetector CT.Radiographics 2006;26(4):1119–31.8. Ekeh AP, Saxe J, Walusimbi M, et al. Diagnosis ofblunt intestinal and mesenteric injury in the era ofmultidetector CT technology­­are results better? JTrauma 2008;65(2):354–9.9. Kendall JL, Kestler AM, Whitaker KT, Adkisson MM,Haukoos JS. Blunt Abdominal Trauma Patients Areat Very Low Risk for Intra­Abdominal Injury afterEmergency Department Observation. West J EmergMed 2011;12(4):496–504.10. Stephan PJ, McCarley MC, O'Keefe GE, Minei JP.23­Hour observation solely for identification ofmissed injuries after trauma: is it justified? JTrauma 2002;53(5):895–900.

Kong et al. 379

Access full text article onother devices Access PDF of article onother devices