Introduction
Background
The diagnosis and management of bowel trauma has evolved over many centuries.
Historic methods
One of the earliest descriptions of bowel trauma came from the Byzantine Empire (324-1453 CE). The historical writer Philostorgius (fifth century) described the fatal wounding of Emperor Julian the Apostate (361-363 CE) when he wrote, "a cavalryman severely wounded the emperor in the abdomen with his spear and injured the peritoneum and intestines; when the point of the weapon was pulled out, there followed an outflow of feces mixed with blood."1,2
For centuries, bowel trauma was managed conservatively, with occasional reports of the reduction of prolapsed portions of the GI tract. This treatment had a high mortality rate, and survivors escaped death by withstanding hemorrhage and sepsis.3,4
With the introduction of firearms at the Battle of Crecy in 1346, penetrating abdominal wounds became more severe. The first exploratory laparotomy was performed in 1834 by a French surgeon named ML Baudens. Baudens also recommended introducing a finger or small sponge through the abdominal wound to determine the presence of blood, feces, or bubbles of gas and, if present, to proceed with a laparotomy. This was the first diagnostic evaluation for bowel injury.
In the early 1900s, Nicholas Senn, a surgeon, proposed to diagnose intestinal perforation using a technique termed the Senn hydrogen gas insufflation test. This diagnostic test involved insufflating hydrogen gas into the anus of a wounded patient. A lighted taper was then placed near the entrance wound. If a small explosion accompanied by a flaring blue flame occurred, this was considered a positive finding for intestinal perforation.
A turning point in the conservative management of penetrating bowel trauma came after the assassination of President James Garfield in 1881. Although he was managed conservatively and died 3 months later of a mycotic aneurysm, his death brought the debate of abdominal exploration to academic discussion.
During WWII, soldiers presenting with penetrating wounds underwent radiographic examinations, had nasogastric tubes inserted, received penicillin, and underwent exploratory laparotomy. From WWII to the Vietnam War, mortality from penetrating gunshot wounds decreased from 42% to 9%.5
With the introduction of radiography in the evaluation of blunt abdominal trauma, diagnostic accuracy improved. Abdominal radiographs could detect as little as 1 cm3 of free gas outside the intestinal tract. However, plain radiographs were nonspecific. Addition of conventional contrast procedures helped by identifying extravasation from perforated viscera.
Modern methods
In 1965, diagnostic peritoneal lavage (DPL) was introduced. DPL involves making a small midline incision and instilling 1 L normal saline or Ringer lactate into the peritoneum. Eluted fluid is examined for blood, particulate matter (fecal, vegetable), or bacteria.
In 1971, the use of ultrasound (US) to evaluate blunt abdominal trauma was first reported. During this period, angiography also was used to evaluate blunt abdominal trauma to detect mesenteric, retroperitoneal, or solid organ hemorrhage.
The use of CT to evaluate blunt abdominal trauma was first reported in 1979, when an EMI scanner was used to study blunt trauma in 4 patients. The identified injuries included lacerated spleen, hepatic hematoma, and 2 renal hematomas.
Since 1979, the resolution and scanning time of CT have improved, as well as its ability to detect bowel injury. Multi-row helical detector CT scans are capable of scanning the abdomen in less than 30 seconds and can detect free air, free fluid, abnormal bowel wall enhancement, bowel wall thickening, and mesenteric infiltration. These advances in CT have brought the debate of conservative management of abdominal trauma full circle. Currently, many patients with blunt abdominal trauma or retroperitoneal penetrating trauma can be managed without surgery and can avoid unnecessary laparotomy.
A 47-year-old man with blunt trauma to the abdomen. Axial CT through upper abdomen reveals 2 spots of free intraperitoneal air (arrows).
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.
Multidetector CT scanning using 16- and 64-slice CT has increased the speed in which trauma patients are scanned. In addition, 16- and 64-slice multidetector CT imaging allows the creation of isotropic voxels that allow reformats to be performed in sagittal and coronal planes, which can allow better localization of bowel injuries. CT is used in 3-dimensional reconstructions of the colon (CT colonography). The use of CT to reconstruct the entire alimentary tract to detect bowel trauma is not unreasonable.
Interventional radiology and techniques of minimally invasive surgery also are revolutionizing treatment of bowel trauma. Laparoscopy is being used in hemodynamically stable patients with blunt abdominal trauma to identify and repair small bowel injuries.6 Percutaneous management of abscesses and hematomas provides a minimally invasive, although sometimes only temporary, alternative to open exploratory laparotomy in patients who may have multiple other injuries.
Pathophysiology
Bowel injury can result from both blunt and penetrating trauma to the abdomen. Blunt trauma is the most common mechanism of injury to the bowel. Of patients with blunt abdominal trauma, 5% will have intestinal and mesenteric injury. Blunt trauma can occur from vehicular accidents, falls, and assaults. Penetrating trauma to the gut occurs more frequently in the urban setting and typically is secondary to knife or gunshot wounds.
- Blunt abdominal trauma: The physical forces involved in the mechanism of injury to the bowel in blunt abdominal trauma can be divided into 2 categories: compression forces and deceleration forces.
- Compression forces act by increasing the intraluminal pressure in the bowel or by compressing fluid-filled bowel against solid structures (eg, duodenal compression on the spine). Compressive forces result in a spectrum of injuries that range from stretching the bowel wall to full-thickness perforation.
- Deceleration forces cause stretching and tearing of bowel loops at points of fixation, such as the ligament of Treitz, the ileocecal valve, and the phrenocolic ligament. Deceleration injuries range from tearing the bowel wall, to shearing the mesentery, to loss of vascular supply to the segment of gut.
- Penetrating trauma: The spectrum of injury from penetrating trauma ranges from abrasion of the serosa, to full-thickness penetration of the bowel wall in 1 or multiple areas, to mesenteric and vascular injury.
Frequency
United States
In the United States, trauma is the leading cause of death in men and women younger than 40 years and is the third leading cause of death in all age groups.
International
In industrialized countries, trauma is the leading cause of death among individuals aged 1-40 years. Worldwide, 1 in 10 deaths occur from traumatic injuries. Specific statistics regarding trauma to the bowels is not available.
Mortality/Morbidity
The abdomen is the third most commonly injured body region, and 10% of trauma deaths result from abdominal injuries. Morbidity and mortality in bowel trauma occur as a result of hemorrhage of injured mesenteric vessels or peritonitis from bowel wall rupture.
Sex
Overall, males have a higher incidence of traumatic injuries than females.
Age
Traumatic injury is the leading cause of death in males and females aged 1-40 years.
Anatomy
Each anatomic region of the GI tract is associated with characteristic patterns of injury. Most full-thickness gastric injuries result from penetrating trauma. Blunt abdominal gastric trauma occurs after a full meal. The most common site of gastric rupture is the anterior wall, followed by the greater curvature, the lesser curvature, and the posterior wall.
Of duodenal injuries, 75% are secondary to penetrating trauma and 25% to blunt trauma. Blunt duodenal injury usually occurs in the second or third portion of the duodenum, where the duodenum can be compressed against the spine. Shearing injury also can occur adjacent to the ligament of Treitz. Duodenal injuries include duodenal wall hematoma, which can be managed without surgery, and duodenal wall rupture, which requires emergent surgery.
Injury often occurs near points of fixation, such as the ligament of Treitz or ileocecal valve. Rupture often occurs along the antimesenteric border.
Colonic injury can occur from both penetrating and blunt trauma. Blunt trauma frequently involves compressive injury to the transverse colon, the sigmoid colon, or the cecum.
Presentation
Evaluation of a patient with potential bowel trauma includes the following steps:
- Initially, assess the patient's airway, breathing, and circulation.
- During the secondary survey, examine the abdomen to identify swelling, bruising, scratches, and areas of skin penetration.
- Assess bowel sounds.
- Carefully palpate the abdomen, first in the area of least tenderness, and then extend the palpation to the perceived area of tenderness or injury.
Swelling, bruising, skin penetration, lack of bowel sounds, guarding, and direct and rebound tenderness suggest the possibility of bowel injury. Clinical signs of bowel injury (ie, abdominal tenderness, rigidity, absent bowel sounds) are present in only 31% of patients.
Preferred Examination
CT of the abdomen is the preferred diagnostic examination for the evaluation of blunt abdominal trauma in the hemodynamically stable patient with blunt abdominal trauma and in selected instances of penetrating trauma to the posterior abdomen. Unstable patients or patients with penetrating injuries to the abdomen undergo exploratory laparotomy.7
Abdominal CT examination should be systematic.
- Traumatic injury to the bowel is rarely isolated.
- First, evaluate the more commonly injured organs, such as the liver and spleen, as well as the pancreas, adrenals, kidneys, blood vessels, spine, and skeletal structures.
- Evaluate traumatic injury to the bowel in the context of the mechanism and location of injury.
- Right upper quadrant: Examine the right lung base, right hemi-diaphragm, liver, gallbladder, right colon, right adrenal, right kidney, and right abdominal small bowel loops.
- Midline: Evaluate the base of the heart, diaphragm, pancreas, duodenum, aorta, inferior vena cava, and small bowel mesentery.
- Left upper quadrant: Evaluate the base of the heart, base of the left lung, left hemi-diaphragm, stomach, spleen, tail of the pancreas, left adrenal, left kidney, left colon, and small bowel loops.
- Lower abdomen and/or pelvis: Evaluate the bladder, rectosigmoid, and small bowel loops.
Each imaging modality (eg, plain abdominal radiograph, US, CT) demonstrates typical findings that suggest a diagnosis of bowel trauma. In the hemodynamically stable patient with abdominal trauma, CT is the study of choice.
Limitations of Techniques
The accuracy of CT for the evaluation of bowel injury is as high as 97.6%.
CT can be limited if DPL is performed prior to the CT. Free intraperitoneal fluid and air from the DPL observed on CT makes the evaluation for bowel injury very difficult.
Although CT can suggest bowel injury by demonstrating free intraperitoneal air, free fluid, or thickened bowel wall, in many instances it cannot reliably localize the exact location of bowel injury.
Delayed presentation of bowel injury occasionally occurs. Patients returning with continued symptoms several hours or days after a negative trauma should undergo repeat CT.8
Differential Diagnoses
Other Problems to Be Considered
Free air (also seen with pneumomediastinum, pneumothorax, recent DPL, laparotomy, barotrauma)
Free fluid (also caused by injury to other organs including liver, spleen, gallbladder, urinary bladder)
Bowel wall thickening (also seen with various enteritis or colitides including ischemic, inflammatory, pseudomembranous)
Abnormal bowel wall enhancement (also seen in hypotensive "shock bowel")
More on Bowel, Trauma |
 Overview: Bowel, Trauma |
| Imaging: Bowel, Trauma |
| Follow-up: Bowel, Trauma |
| Multimedia: Bowel, Trauma |
| References |
| Further Reading |
| Next Page » |
References
Lascaratos J, Voros D. Fatal wounding of the Byzantine Emperor Julian the Apostate (361-363 A.D.): approach to the contribution of ancient surgery. World J Surg. May 2000;24(5):615-9. [Medline].
Mettler CC, Mettler FA. Byzantine surgery. History of Medicine. 1947:824-5.
Nance FC. Abdominal trauma at the Southern Surgical Association, 1888-1987. Ann Surg. Jun 1988;207(6):742-53. [Medline].
Rutkow IM. The nineteenth century. In: Surgery: An Illustrated History. St. Louis, Mo: Mosby-Year Book; 1994:. 488.
Busić Z, Lovrić Z, Amić E, et al. Small bowel injuries in penetrating abdominal trauma during war: ten-year follow-up findings. Mil Med. Sep 2004;169(9):721-2. [Medline].
Mathonnet M, Peyrou P, Gainant A, et al. Role of laparoscopy in blunt perforations of the small bowel. Surg Endosc. Apr 2003;17(4):641-5. [Medline].
Taourel P, Merigeaud S, Millet I, Devaux Hoquet M, Lopez F, Sebane M. [Trauma of the thoraco-abdominal area: imaging strategy]. J Radiol. Nov 2008;89(11 Pt 2):1833-54. [Medline].
Kaban G, Somani RA, Carter J. Delayed presentation of small bowel injury after blunt abdominal trauma: case report. J Trauma. May 2004;56(5):1144-5. [Medline].
Anderson SW, Soto JA. Anorectal trauma: the use of computed tomography scan in diagnosis. Semin Ultrasound CT MR. Dec 2008;29(6):472-82. [Medline].
Yagan N, Auh YH, Fisher A. Extension of air into the right perirenal space after duodenal perforation: CT findings. Radiology. Mar 2009;250(3):740-8. [Medline].
Delabrousse E, Lubrano J, Sailley N, Aubry S, Mantion GA, Kastler BA. Small-bowel bezoar versus small-bowel feces: CT evaluation. AJR Am J Roentgenol. Nov 2008;191(5):1465-8. [Medline].
Katz DS, Yam B, Hines JJ, Mazzie JP, Lane MJ, Abbas MA. Uncommon and unusual gastrointestinal causes of the acute abdomen: computed tomographic diagnosis. Semin Ultrasound CT MR. Oct 2008;29(5):386-98. [Medline].
Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma. Feb 2004;56(2):314-22. [Medline].
Brody JM, Leighton DB, Murphy BL, et al. CT of blunt trauma bowel and mesenteric injury: typical findings and pitfalls in diagnosis. Radiographics. Nov-Dec 2000;20(6):1525-36; discussion 1536-7. [Medline].
Druy EM, Rubin BE. Computed tomography in the evaluation of abdominal trauma. J Comput Assist Tomogr. Feb 1979;3(1):40-4. [Medline].
Gay SB, Sistrom CL. Computed tomographic evaluation of blunt abdominal trauma. Radiol Clin North Am. Mar 1992;30(2):367-88. [Medline].
Hamilton P, Rizoli S, McLellan B, Murphy J. Significance of intra-abdominal extraluminal air detected by CT scan in blunt abdominal trauma. J Trauma. Aug 1995;39(2):331-3. [Medline].
Hauser CJ, Huprich JE, Bosco P, et al. Triple-contrast computed tomography in the evaluation of penetrating posterior abdominal injuries. Arch Surg. Oct 1987;122(10):1112-5. [Medline].
Killeen KL, Shanmuganathan K, Poletti PA, et al. Helical computed tomography of bowel and mesenteric injuries. J Trauma. Jul 2001;51(1):26-36. [Medline].
Lamki N, Raval B. The role of computed tomography in abdominal and pelvic trauma. J Comput Tomogr. Sep 1982;6(2):113-9. [Medline].
Scaglione M, de Lutio di Castelguidone E, Scialpi M, et al. Blunt trauma to the gastrointestinal tract and mesentery: is there a role for helical CT in the decision-making process?. Eur J Radiol. Apr 2004;50(1):67-73. [Medline].
Kauffmann GW, Wenz W, Strecker EP, Kotoulas K. Indications and use of abdominal angiography in trauma. Cardiovasc Radiol. 1979;2(1):35-40. [Medline].
Miller PR, Croce MA, Bee TK, et al. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma. Aug 2002;53(2):238-42; discussion 242-4. [Medline].
Adams DB. Abdominal gunshot wounds in warfare: a historical review. Mil Med. Jan 1983;148(1):15-20. [Medline].
Burney RE, Mueller GL, Coon WW, et al. Diagnosis of isolated small bowel injury following blunt abdominal trauma. Ann Emerg Med. Feb 1983;12(2):71-4. [Medline].
Derby AC. Wounds of the abdomen. Part 1: In war. Can J Surg. Jul 1988;31(4):213-8. [Medline].
Dunphy JE. The cut gut. Am J Surg. Jan 1970;119(1):1-8. [Medline].
Federle MP. Abdominal trauma. In: Gore RA, Levine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. Philadelphia, Pa: WB Saunders; 2000:. 2255-61.
Jurkovich GJ, Carrico CJ, Sabiston DC. Trauma management of the acutely injured patient. In: Sabiston Textbook of Surgery. 3rd ed. Philadelphia, Pa: WB Saunders; 1997:. 296-339.
Kurtzman RS. Radiology of blunt abdominal trauma. Surg Clin North Am. Feb 1977;57(1):211-26. [Medline].
Mizzi A, Shabani A, Watt A. The role of follow-up imaging in paediatric blunt abdominal trauma. Clin Radiol. Oct 2002;57(10):908-12. [Medline].
Murray CJL. How the world dies today. In: Murray CJL, Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability. Cambridge, Mass: Harvard University Press; 1996:. 116-200.
National Center for Injury Prevention and Control. 10 Leading Causes of Death, United States 1981-1998, All Races, Both Sexes. Available at: http://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Atlanta, Ga: Centers for Disease Control and Prevention. [Full Text].
Novelline RA, Rhea JT, Bell T. Helical CT of abdominal trauma. Radiol Clin North Am. May 1999;37(3):591-612, vi-vii. [Medline].
Rizzo MJ, Federle MP, Griffiths BG. Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT. Radiology. Oct 1989;173(1):143-8. [Medline].
Root HD, Hauser CW, McKinley CR, et al. Diagnostic peritoneal lavage. Surgery. May 1965;57:633-7. [Medline].
Rozycki GS. Abdominal ultrasonography in trauma. Surg Clin North Am. Apr 1995;75(2):175-91. [Medline].
Silen W. Cope's Early Diagnosis of the Acute Abdomen. 18th ed. Oxford University Press;1991:30-7.
Smith RC, O''Leary JP. To cut or not to cut: the evolution of exploratory laparotomy for abdominal gunshot wounds. Am Surg. Apr 1999;65(4):388-9. [Medline].
Uppot RU, Gheyi VK, Gould SW. Trauma Cases from the Medical Center of Delaware: Intestinal Perforation from Blunt Trauma to an Inguinal Hernia. AJR Am J Roentgenol. 2000;174:1538.
Wing VW, Federle MP, Morris JA, et al. The clinical impact of CT for blunt abdominal trauma. AJR Am J Roentgenol. Dec 1985;145(6):1191-4. [Medline].
World Health Organization. Injury: A Leading Cause of the Global Burden of Disease. In: Violence Injury and Prevention. Geneva, Switzerland; 1999.
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
