Author: Ines Obolo
Trauma represents a leading cause of mortality worldwide. Abdominal trauma represents 7% of trauma cases and 15-20% of severe adult trauma cases. Abdominal trauma can be classified into blunt or penetrating trauma. Blunt abdominal trauma includes injury to solid and hollow viscus organs. Frequently injured organs: spleen, liver, small bowel. Traumatic hollow viscus mesenteric injury (HVMI) are rare, life-threatening injuries[4,5] and can be due to direct impact, deceleration, and increased luminal pressure. With the deceleration mechanism, there is a rapid change in velocity with the differential movement of mobile and fixed parts of the body. Mesenteric disinsertion, also known as bucket handle mesenteric injury is an example of deceleration injury. A bucket handle mesenteric injury is an avulsion of a mesentery out of a segment of bowel due to shearing forces in blunt abdominal trauma . This injury results in intestinal ischaemia and if left untreated may progress to intestinal necrosis, perforation and peritonitis[1,8]. This injury is commonly encountered in the course of a motor vehicle accident, often associated with restraint device injury (lap seat belt, shoulder harness)[2,9,10]. Under the umbrella of traumatic HVMI, small bowel injuries represent more than half of the cases. Bruising in a seatbelt pattern is associated with intra-abdominal injury in 20–60% of cases. The diagnostic modality for HVMI depends on the hemodynamic status of the patient. Stable patients get CT scan, while the unstable get an ultrasound – Focused Assessment with Sonography for Trauma (FAST). The early management of traumatic HVMI begins with a primary survey and resuscitation. The injury is commonly missed during the first days following trauma. Treatment involves resection of devitalized bowel segment and anastomosis of the bowel. Surgery should not be delayed in patients presenting with hemodynamic instability, pneumoperitoneum, peritonitis and CT signs of mesenteric ischaemia[6,8].
A 53-years-old patient who diagnosed with type 2 diabetes mellitus over 5 years ago, on metformin non-compliant to treatment, known hypertensive, treated with indapamide is presented to the ED. He was involved in a motor vehicle accident involving a head-on collision of two vehicles at fast speed. He was a passenger and was compressed by his lap seat belt at the moment of collision. He complained of diffuse abdominal pain, no loss of consciousness. On clinical exam, the patient was stable, with a right flank ecchymosis, diffuse abdominal tenderness and tender Douglas pouch. CT scan done found peri-hepatic hematoma with no free air in the peritoneal cavity. A laparotomy with midline incision was done and the peroperative findings were: about 1.5L of bloody intra-abdominal fluid, 3cm perforation of the ileum 80cm proximal to the ileocecal junction, ileal mesenteric disinsertion with bowel necrosis. The repair consisted of resection of devitalized ileum and end-to-end anastomosis. Post-operatively, the patient had pulmonary sepsis with acute respiratory distress syndrome, grade II hypertension and hyperglycaemia and was managed at the intensive care unit. The evolution was favourable on day 14 post-op with medication: antibiotics, insulin and antihypertensive (calcium channel blocker – amlodipine). Sutures were removed on day 14 post-op and he was discharged on day 20 post-op.
Blunt abdominal trauma results in injury to the bowel and mesenteries in 3—5% of cases. It has a variable presentation with hematoma, seromuscular tear, ischaemia, perforation[5,6]. Our patient is male and aged 53 years comparable to studies[2,3] that demonstrate the predominance of male sex in abdominal trauma with a mean age range of 30-39 years with extremes at 15 and 67years. The patient incurred a blunt abdominal trauma in the course of a motor vehicle accident and presented with a seat belt sign this is similar to studies that report patients often being victims of motor vehicle accidents [2,8,11] with or without restrain devices. The use of restraint devices is responsible for traumatic lesions to hollow organs. Literature review incriminates poor seat belt usage in particular lap seatbelt as a cause of mesenteric injuries during blunt trauma. Diffuse abdominal tenderness and tenderness on digital rectal examination (DRE) were present on physical exam. Tenderness on DRE is rare while abdominal tenderness is a non-specific sign of abdominal trauma and is encountered in all types of injury involving the abdomen. A CT was done for the patient which found peri-hepatic hematoma and no mesenteric lesion. CT scan represents the most sensitive diagnostic imaging modality with a sensitivity ranging from 59% to 95% though cases of false negatives (lesions found during laparotomy absent in CT) have been reported. The perioperative findings were small bowel ischaemia following mesenteric disinsertion, necrosis and perforation consistent with review findings [6,12]. The lesions were located over the ileal segment. This is consistent with studies as the small bowel is the most injured organ in blunt abdominal trauma[2,3,5]. The surgical management consisted of resection of the ileal segment and end-to-end anastomosis per studies[2,3,5] that mention the management of traumatic HVMI to be the removal of devitalized bowel and restoration bowel continuity. Traumatic injuries to hollow viscous and mesenteric represent a diagnostic challenge, admission delays aggravate prognosis and are due to the lack of functional emergency services in our context. The patient presented with hypertension, hyperglycaemia and pulmonary sepsis after his surgery with no cardiovascular event nor kidney injury. According to a review, hypertension increases perioperative cardiovascular complications by 35% and the management depends on other comorbidities with beta-blockers often used. In diabetic patients undergoing surgery, an assessment of glycaemic control with recent capillary blood sugar level is recommended as diabetes could present several risks including cardiovascular events, acute kidney injury and infectious complications. This emphasizes the need for proper postoperative management of high-risk patients. This case highlights the reality of hollow viscus and mesenteric injuries despite their scarcity and the fact that they often present as missed lesions with high mortality[8,10]. These injuries represent a challenge in clinical assessment and management, especially in high-risk patients who should be closely monitored pre and postoperatively[7,14].
Traumatic Bucket handle mesenteric injuries are rare and challenging to diagnose. As with this case, a high suspicion should exist for every patient involved in a motor vehicle accident wearing a restraint device. Equally, the physician should rely on the findings of a thorough physical examination. Early management is key to reducing morbidity and mortality.
References and Further Reading
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3. Abebe K, Bekele M, Tsehaye A, Lemmu B, Abebe E. Laparotomy for Abdominal Injury Indication & Outcome of patients at a Teaching Hospital in Addis Ababa, Ethiopia. Ethiop J Health Sci. 2019 Jul;29(4):503–12.
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10. American College of Surgeons, Committee on Trauma. Advanced trauma life support: student course manual. 2018.
11. Wisner DH, Chun Y, Blaisdell FW. Blunt intestinal injury. Keys to diagnosis and management. Arch Surg Chic Ill 1960. 1990 Oct;125(10):1319–22; discussion 1322-1323.
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14. Cheisson G, Jacqueminet S, Cosson E, Ichai C, Leguerrier A-M, Nicolescu-Catargi B, et al. Perioperative management of adult diabetic patients. Preoperative period. Anaesth Crit Care Pain Med. 2018 Jun;37 Suppl 1:S9–19.