Proximal jejunal transection

Tad T. Renvyle, MD and Kimball G. C

View content online at: http://www.appliedradiology.com/Issues/2000/08/Cases/Proximal-jejunal-transection.aspx

Abstract:  22-year-old man presented to the emergency department complaining of abdominal pain after sustaining blunt trauma to his abdomen in a motorcycle accident. Physical examination revealed an epigastric abrasion, diffuse abdominal tenderness, and absent bowel sounds. Laboratory test results showed an hemato-crit of 48 and a white blood cell count of 21.8. A computed tomographic (CT) exam was performed followed by gastrograffin enema. Twenty-four hours later an upper gastrointestinal series was performed, followed by laparotomy.

Loading...
Diagnosis

Proximal jejunal transection

Findings

CT examination of the abdomen and pelvis with oral and intravenous contrast demonstrated a left rectus sheath hematoma. The subjacent small bowel showed wall thickening with intramural low attenuation regions thought to represent hematoma (figure 1A). A small amount of free fluid was present in the pelvis (figure 1B). No free air was observed. Due to fat stranding of the left lateroconal fascia adjacent to the descending colon (figure 1A), a gastrograffin enema was performed to rule out colonic injury. No colonic abnormality was seen, and the patient was admitted for observation.

Due to continued patient complaints of abdominal pain and vomiting, a gastrograffin upper gastrointestinal series was performed. Initial images showed gastroesophageal reflux. Subse-quent imaging showed contrast to flow promptly through a dilated duodenum and come to an abrupt halt in the proximal jejunum with a "beaked" appearance (figure 2). Scant amounts of contrast extending from this "beak" were seen to outline a mass. A diagnosis of traumatic obstruction was made.

The patient was taken to the operating room where a proximal jejunal transection was found. The mass outlined by contrast was omentum wrapped around and sealing off the transected jejunum. Three liters of fluid were removed from the peritoneal cavity, the injured bowel was resected, and a primary small bowel anastomosis was performed. After a 1-week stay in the intensive care unit and drainage of residual pelvic fluid collections, the patient recovered well without complication.

Discussion

Small bowel laceration/perforation occurs in 3% to 5% of cases of blunt abdominal trauma.1-3 The classic triad of small bowel injury (rigid abdomen, tenderness, absent bowel sounds) occurs in only one-third of patients.1 The detection of this subset of trauma patients has improved markedly with CT, which has led to a decrease in the number of negative laparotomies performed in the setting of blunt abdominal trauma.4

In the setting of blunt abdominal trauma, CT has a sensitivity of 92%, a specificity of 94%, a positive predictive accuracy of 30%, and a negative predictive accuracy of 100% for the diagnosis of small-bowel laceration/contusion.2 Common CT signs of small bowel perforation in order of decreasing frequency include: peritoneal free fluid (80%), bowel wall thickening (60%), free air (40%), and contrast extravasation (15%).1,2 Hemoperitoneum can be diagnosed when the free fluid collections measure >30 HU, with an average of 45 HU if <48 hours old.5 Free air and contrast extravasation are found in only half of patients with small-bowel perforation, but are each nearly 100% specific for bowel perforation.1 One other sign of small bowel rupture is the streaky mesentery sign. In one series, this was found in 70% of patients with small-bowel perforation on the mesenteric side.3 Although no one sign is 100% sensitive, the presence of multiple signs carry a 90% sensitivity and 95% specificity.2

When small bowel, particularly duodenal, injury is present, there is a high association of solid organ injury. These include pancreas (45%), liver (30%), spleen (25%), and kidney (10%).5,6 There is also a 15% incidence of colonic injury.7 The presence of these other injuries may delay diagnosis of small bowel injury; to avoid this a thorough examination of the small bowel should be performed when these injuries are present.3 Extraperitoneal injuries may also mask small bowel injury, particularly retroperitoneal and rectus sheath hematomas, as in this case.6 If treatment of small bowel perforation is delayed, mortality rises dramatically from 5% to 65%.1,8

If abdominal complaints persist after an initial CT shows no bowel injury, continued surveillance is warranted. A surgical series from Canada has reported delayed intestinal perfor-ation after blunt abdominal trauma.9 All patients had persistent complaints of abdominal pain. Three-quarters of the patients had spinal injury. All had either direct insult to the bowel or the mesenteric vessels, with 75% showing adjacent mesenteric hematoma.9 Continued surveillance with CT is widely accepted.8 The role of other contrast studies such as UGI series is not yet clearly defined.l,8


REFERENCES

1. Rizzo MJ, Federle MP, Griffiths BG: Bowel and mesenteric injury following blunt abdominal trauma: Evaluation with CT. Radiology 173:143-148, 1989.

2. Sherck J, Shatney C, Sensaki K, Selivanov V: The accuracy of computed tomography in the diagnosis of blunt small bowel perforation. Am J Surg 168:670-675, 1994.

3. Hagiwara A, Yukioka T, Satou M, et al: Early diagnosis of small intestine rupture from blunt abdominal trauma using computed tomography: Significance of the streaky density within the mesentery. J Trauma 38:630-633, 1995.

4. Wing VW, Federle MP, Morris JA Jr, et al: The clinical impact of CT for blunt abdominal trauma. AJR 145:1191-1194, 1985.

5. Wolfman NT, Bechtold RE, Scharling ES, Meredith JW: Blunt upper abdominal trauma: Evaluation by CT. AJR 158:493-501, 1991.

6. Federle MP, Goldberg HI, Kaiser JA, et al: Evaluation of abdominal trauma by computed tomography. Radiology 138:637-644, 1981.

7. Weissleder R, Rieumont MJ, Wittenberg J: Primer of Diagnostic Imaging, 2nd ed, p. 167. St Louis, Mosby, 1997.

8. Cone JB, Eidt JF: Delayed diagnosis of duodenal rupture. Am J Surg 168:676-679, 1994.

9. Winton TL, Girotti MJ, Manley PN, Sterns EE: Delayed intestinal perforation after nonpenetrating abdominal trauma. Can J Surg 28:437-439, 1985.

  1. Rizzo MJ, Federle MP, Griffiths BG: Bowel and mesenteric injury following blunt abdominal trauma: Evaluation with CT. Radiology 173:143-148, 1989.
  2. Sherck J, Shatney C, Sensaki K, Selivanov V: The accuracy of computed tomography in the diagnosis of blunt small bowel perforation. Am J Surg 168:670-675, 1994.
  3. Hagiwara A, Yukioka T, Satou M, et al: Early diagnosis of small intestine rupture from blunt abdominal trauma using computed tomography: Significance of the streaky density within the mesentery. J Trauma 38:630-633, 1995.
  4. Wing VW, Federle MP, Morris JA Jr, et al: The clinical impact of CT for blunt abdominal trauma. AJR 145:1191-1194, 1985.
  5. Wolfman NT, Bechtold RE, Scharling ES, Meredith JW: Blunt upper abdominal trauma: Evaluation by CT. AJR 158:493-501, 1991.
  6. Federle MP, Goldberg HI, Kaiser JA, et al: Evaluation of abdominal trauma by computed tomography. Radiology 138:637-644, 1981.
  7. Weissleder R, Rieumont MJ, Wittenberg J: Primer of Diagnostic Imaging, 2nd ed, p. 167. St Louis, Mosby, 1997.
  8. Cone JB, Eidt JF:Delayed diagnosis of duodenal rupture. Am J Surg 168:676-679, 1994.
  9. Winton TL, Girotti MJ, Manley PN, Sterns EE: Delayed intestinal perforation after nonpenetrating abdominal trauma. Can J Surg 28:437-439, 1985.