E2621. Don’t Delay! Signs and Consequences of Mesenteric Injury
  1. Nil Rawal; Rutgers New Jersey Medical School
  2. Thomas Schwedhelm; Rutgers New Jersey Medical School
  3. John Sabatino; Rutgers New Jersey Medical School
  4. Robert Dym; Rutgers New Jersey Medical School
  5. Andrzej Jedynak; Rutgers New Jersey Medical School
  6. Humaira Chaudhry; Rutgers New Jersey Medical School
  7. Inessa Goldman; Rutgers New Jersey Medical School
Mesenteric and bowel injuries constitute 3-5% of blunt abdominal injuries, the third most common type of blunt abdominal trauma. Detection of significant bowel and mesenteric injury remains challenging and may result in diagnostic delay, with subsequent increase in mortality and morbidity. While many radiologic findings of bowel and mesenteric injury requiring surgery are defined, they frequently lack sensitivity. Several radiologic and surgical scoring scales, combining radiological and clinical signs, have been proposed in an attempt to improve accuracy for predicting bowel injury and need for surgery. Delayed bowel injury is a rare, but clinically significant entity related to sequela of underestimated severity of mesenteric injury, which may lead to bowel perforation or obstruction days to months after initial presentation. We present a spectrum of radiologic signs observed with small bowel and mesenteric injury, emphasizing findings associated with delayed bowel injury, that can help the clinician and radiologist to have a heightened index of suspicion for these injuries.

Educational Goals / Teaching Points
Review clinical and radiographic signs associated with blunt small bowel and mesenteric injury. Demonstrate recently proposed surgical and radiological grading systems for objective assessment of mesenteric injury. Illustrate and raise awareness regarding mechanisms in rare, delayed bowel injury cases, with emphasis on concomitant radiological and clinical signs which may suggest bowel injury.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
We discuss the mechanisms and pathophysiology of mesenteric and bowel injury and review associated clinical findings such as seatbelt sign, abdominal tenderness, leukocytosis, hypotension, and airbag deployment. We present emerging scoring systems for mesenteric and bowel injury, including the Bowel Injury Prediction Score and the scoring scale presented by Faget et al. Computed Tomography imaging examples of each grade of mesenteric/bowel injury 1 through 5 are presented including mesenteric contusion and hematoma, bowel wall thickening, pneumoperitoneum, hemoperitoneum, active contrast extravasation, and patchy hypo-enhancement of bowel indicative of poor bowel perfusion. Cases of significant bowel injury accompanying relatively minor falls, especially in an elderly population, are presented. We demonstrate delayed bowel injury through a case-based discussion. Findings suggesting increased severity of abdominal injury, including seatbelt-like symptoms, and focal intramural aortic hematoma among others are emphasized. Divergent pathophysiology in cases of delayed bowel injury, resulting in either delayed bowel perforation or stricture formation and small bowel obstruction are discussed.

Scoring scales for mesenteric and bowel injuries are emerging as a potentially promising tool that the radiologist and clinician may utilize to identify bowel injuries that may require surgery. Radiologists should have a high degree of suspicion for signs of delayed bowel injury in patients with history of previous mesenteric injury.