Radiography
Findings
Plain radiography findings in bowel injury include the following:
- Nonspecific findings may include small and/or large bowel dilation suggestive of ileus or obstruction secondary to peritonitis.
- Soft tissue density and/or mass effect on bowel gas loops suggest fluid collections, hematoma, or scoliosis resulting from splinting toward the side of injury.
- Loss of right psoas shadow suggests a retroperitoneal fluid collection from a duodenal injury.
- Free intraperitoneal air suggests bowel perforation.
- Upright abdominal films and left lateral decubitus films can detect as little as 1 mL or 2 mL of free intraperitoneal air under the diaphragm or over the liver edge, respectively.
- On supine abdominal radiographs, free air can be observed outlining the serosa of the bowel loops ("Rigler" or serosa sign) or the falciform ligament.
- Retroperitoneal air from duodenal or sigmoid injury can outline the diaphragmatic crura or the kidneys.
- GI studies using contrast can identify areas of extravasation from perforated bowel. GI studies also can help identify a duodenal hematoma.
Degree of Confidence
Plain radiographs are not highly specific or sensitive for evaluating bowel injury. Findings of free air, abdominal fluid, scoliosis, and psoas shadow obliteration are observed in fewer than 43% of patients with intestinal trauma. Fluid collections must be large (>800 mL) to be visible on plain radiographs.
False Positives/Negatives
Pneumoperitoneum does not always indicate bowel rupture and can be observed in patients with pneumomediastinum, pneumothorax, and in patients on mechanical ventilation.
Computed Tomography
A 47-year-old man with blunt trauma to the abdomen. Axial CT through upper abdomen reveals 2 spots of free intraperitoneal air (arrows).
A 15-year-old boy with blunt trauma to the abdomen and a perforated stomach. Axial CT demonstrates large amount of free intraperitoneal air (green arrow). An air/fluid level with fluid is seen in the right paracolic gutter (red arrow). Extravasated oral contrast is seen in the left paracolic gutter (blue arrow) adjacent to the stomach.
Patient in a motor vehicle collision with injury to the spleen. Axial CT through the abdomen shows thickening and enhancement of bowel wall in the left lower quadrant resulting from hypotension and hypoperfusion of the bowel. No bowel injury was seen.
A 47-year-old man with blunt trauma to the abdomen. Axial CT through the level of the pelvis shows small bowel wall thickening and enhancement (red arrow) from blunt small bowel injury. Free intraperitoneal air visualized (blue arrow) is from a perforated sigmoid colon. Image from AJR 2000;174:1538 printed with permission from American Roentgen Ray Society.
A 19-year-old man with right-sided chest trauma. Axial CT through the upper abdomen shows a large amount of right retroperitoneal air surrounding the right kidney (arrows). Some air is seen in the right subcutaneous tissues. Retroperitoneal air dissected downwards from a right-sided chest pneumothorax.
Patient with blunt abdominal trauma with duodenal hematoma. Axial CT through the abdomen shows soft tissue density and mild stranding surrounding duodenum (arrow) consistent with a duodenal hematoma.
Female patient with blunt abdominal trauma and duodenal perforation. Focal axial CT of the right upper abdomen shows free intraperitoneal air (red arrow) and contrast extravasation (blue arrow) from the duodenum (yellow arrow).
Female patient with right-sided colon perforation. Axial CT through the abdomen shows focal gas bubbles (red arrow) and anextraluminal fluid collection (blue arrow) adjacent to the contrast-filled colon.
A 79-year-old woman after a motor vehicle collision. Axial CT through the level of the pelvis shows a focal area of small bowel wall thickening (red arrow) consistent with focal blunt small bowel injury. Fat stranding is seen in the mesentery (yellow arrow) consistent with a mesenteric hematoma.
Findings
CT is the modality of choice for evaluating abdominal trauma in the hemodynamically stable patient.9,10,11,12,13,14,15,16,17,18,19,20,21
CT evaluation for blunt abdominal trauma can be difficult and requires strict attention to meticulous techniques.
Administer oral and intravenous contrast. Extend sections from the base of the lungs to below the symphysis pubis. View these sections in the "abdominal, lung, liver" and "bone" windows. Carefully search for associated injuries, including Chance or vertebral burst fractures; abdominal bruising; and pancreatic, liver, spleen, adrenal, and kidney injury. Consider administering rectal contrast in patients with suggested penetrating injury to the rectum or retroperitoneal colon.
Multidetector CT scanning using a 16- or 64-slice CT allows for coronal and sagittal reformats. Examination of these off-axis images allows for improved detection and localization of bowel injuries.
The coronal plane is especially helpful because it provides an anatomic view and helps referring physicians/surgeons better understand the location and extent of injury.
The sagittal plane is helpful in the evaluation of the thoracic and lumbar spine and can detect associated compression fractures of the spine, which may be missed when viewed in the axial plane alone.
CT findings in bowel injury include the following (see Table below):
- Bowel injury is suggested by free intraperitoneal air, free intraperitoneal or retroperitoneal fluid, focal areas of bowel wall thickening, abnormal bowel wall enhancement, bowel wall hematoma (ie, duodenal hematoma), and intramural air.
- The most specific finding is the visualization of oral contrast extravasation and bowel wall disruption.
- A pattern of more diffuse bowel wall thickening, abnormal enhancement, and mesenteric infiltration can suggest mesenteric vascular injury resulting in ischemic bowel.
- In intestinal vascular injury, evaluate the celiac axis, superior mesenteric artery, and superior mesenteric vein. A mesenteric hematoma or a focal area of higher density clotted blood (ie, "sentinel clot") can suggest vascular injury.
- Focal contrast extravasation can indicate active hemorrhage.
Table. CT Findings in Bowel Injury
Open table in new window
Table
| Abdominal CT | Direct Findings | Indirect Findings |
| Bowel injury | Bowel wall disruption and oral contrast extravasation | Free intraperitoneal/retroperitoneal air, free intraperitoneal/retroperitoneal fluid Focal areas of bowel wall thickening, abnormal bowel wall enhancement |
| Mesenteric vascular injury | Intravenous contrast extravasation from the area of the mesentery | Diffuse bowel wall thickening, diffuse bowel wall enhancement, mesenteric infiltration/mesenteric hematoma |
| Abdominal CT | Direct Findings | Indirect Findings |
| Bowel injury | Bowel wall disruption and oral contrast extravasation | Free intraperitoneal/retroperitoneal air, free intraperitoneal/retroperitoneal fluid Focal areas of bowel wall thickening, abnormal bowel wall enhancement |
| Mesenteric vascular injury | Intravenous contrast extravasation from the area of the mesentery | Diffuse bowel wall thickening, diffuse bowel wall enhancement, mesenteric infiltration/mesenteric hematoma |
Degree of Confidence
The accuracy of CT for evaluating bowel injury is 82%, with a sensitivity of 64% and a specificity of 97%.
False Positives/Negatives
Some findings on CT suggesting bowel injury can represent false-positive findings:
- Free intraperitoneal air in a trauma patient also can be observed in a patient with pneumomediastinum, pneumothorax, recent DPL, laparotomy, or barotrauma with no associated bowel injury.
- Free fluid in a trauma patient can originate from injury to other organs, including the liver, spleen, gallbladder, and urinary bladder, without any injury to the bowel.
- Bowel wall thickening and abnormal wall enhancement also can be observed in patients with hypotension or hypoperfusion without direct bowel injury.
Ultrasonography
Findings
Typically, the role of US in evaluating bowel trauma is limited to detecting free intraperitoneal fluid in trauma patients who are not sufficiently hemodynamically stable to undergo CT. However, the identified fluid cannot be further defined. Considerations include benign ascites, blood, urine, or bile and must be confirmed with CT.
Other findings of bowel injury include dilated bowel loops secondary to an ileus or obstruction. US is insensitive in detecting intraperitoneal free air.
Angiography
Findings
The only role of angiography in acute bowel trauma is to identify the site of visceral bleeding.22
More on Bowel, Trauma |
| Overview: Bowel, Trauma |
 Imaging: Bowel, Trauma |
| Follow-up: Bowel, Trauma |
| Multimedia: Bowel, Trauma |
| References |
| Further Reading |
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Further Reading
Related eMedicine topics
Abdominal Trauma, Blunt
Abdominal Trauma, Penetrating
Abdominal Vascular Injuries
Abdominal Trauma (from Pediatrics: Surgery)
Ultrasonography, Abdominal
Clinical guidelines
Clinical Policy: Critical Issues in the Evaluation of Adult Patients Presenting to the Emergency Department With Acute Blunt Abdominal Trauma
ACR Appropriateness Criteria Blunt Abdominal Trauma
Clinical studies
A Colonic Tube to Improve Bowel Function in Spinal Cord Injury
Keywords
bowel trauma, abdominal injuries, intestinal injury, wounds nonpenetrating, wounds penetrating, blunt abdominal trauma
