Delayed rupture of abdominal aortic false aneurysm following blunt trauma

Blunt injury of the abdominal aorta resulting in pseudoaneurysm formation is very rare. Such a pseudoaneurysm may rupture at any time, usually with fatal outcome. We report the case of a 32-year-old man with a clinically unsuspected ruptured abdominal aorta pseudoaneurysm, which had probably formed 3 years earlier, and emphasize the CT features. Electronic Publication     

Small bowel obstruction due to inflammation secondary to ingested bone

We report the CT appearances of an ingested pork bone in the lumen of small bowel in a 66-year-old man with an intact and virgin gastrointestinal tract. CT scan demonstrated the site of obstruction at distal jejunum with associated irregular narrowing and proximal small bowel dilatation as well as the bone lodged in the non-dilated terminal ileum. Laparotomy and histology of the resected small bowel confirmed the CT appearances that the obstruction was caused by adhesions and extensive inflammation across the bowel wall in the distal jejunum from trauma as the bone traversed down the lumen. We believe that this is the first reported preoperative CT scan finding of a case of small bowel obstruction due to adhesions and inflammation secondary to ingested bone.     

Traumatic rupture of the gravid uterus: computed tomographic evaluation

In this report, we describe the computed tomographic findings of a ruptured gravid uterus in a 19-year-old woman involved in a motor vehicle accident. The associated maternal and fetal injuries as well as the likely mechanism of injury are discussed.     

Torsion of the gallbladder: Computed tomographic findings

We report two cases of gallbladder torsion. Computed tomographic findings included marked dilatation, wall thickening, and intraluminal membranous structure of the gallbladder. The extrahepatic bile duct was also dilated.     

Segmental renal infarction after blunt abdominal trauma: Clinical significance and appropriate management

Segmental infarction after blunt trauma is an uncommon type of injury occurring as a result of occlusion of a segmental renal artery. We retrospectively reviewed 32 cases of segmental renal infarction after nonpenetrating injury in order to assess the clinical significance and the most appropriate management. Thirty-five segmental infarcts were demonstrated by contrast medium-enhanced computed tomography (CT), 19 in the left and 16 in the right kidney. Twenty-five of the 35 infarcts (71%) occurred as an isolated renal injury. A distinct upper pole predilection for segmental infarct was observed. Angiography showed an occluded branch vessel without contrast medium extravasation in four cases. None of the 30 surviving patients experienced delayed renal hemorrhage or deterioration of renal function. Only 2 of 24 evaluable patients developed mild diastolic hypertension during follow-up. Our data indicate that segmental renal infarction in the blunt trauma patient, as demonstrated by contrast medium-enhanced CT, should be managed nonoperatively and requires no further evaluation with angiography.     

Blunt trauma to the gastrointestinal tract: CT findings with small bowel and colon injuries

The CT diagnosis of bowel injury is difficult and warrants an organized approach. Careful scrutiny of CT images for extraluminal gas or fluid and bowel wall thickening is required. Review of images of the entire abdomen and pelvis using lung window settings is recommended, followed by the analysis using soft tissue window settings. Specific search for extraluminal fluid collections with a triangular or matted appearance will help detect bowel injury. Electronic Publication     

Small bowel perforation resulting from blunt abdominal trauma: interval change of radiological characteristics

Purpose We analyzed radiography and computed tomography (CT) findings of small bowel perforation due to blunt trauma to identify the keys to diagnosis. Materials and methods Twelve patients with surgically proven small bowel perforation were retrospectively studied. All patients underwent radiography and CT, and five underwent presurgical follow-up CT. Radiological findings were evaluated and correlated to the elapsed time from the onset of the trauma retrospectively. Results Radiography demonstrated free air in only 8% (1/12) and 25% (3/12) at the initial and follow-up examinations, respectively. In contrast, the initial and follow-up CT scans detected extraluminal air in 58% (7/12) and 92% (11/12), respectively. Mesenteric fat obliteration was seen in 58% (7/12) and 75% (9/12) at initial and follow-up CT, respectively. The incidence of both extraluminal air and mesenteric fat obliteration on CT increased as time elapsed, particularly after 8 h. High-density ascites was seen in 75% at initial CT, including two patients without extraluminal air, but was observed in all but one patient at follow-up CT. Conclusion The chance of detecting extraluminal air increases as time elapses. High-density ascites may be seen without extraluminal air and might be an indirect or precedent sign of small bowel perforation. Radiologists need to be familiar with these radiological features.     

Detection of free intraperitoneal air on computed tomography after blunt abdominal trauma

In patients who have sustained blunt abdominal trauma, detection of free intraperitoneal air on computed tomography (CT) is thought to be a fairly specific finding of bowel rupture. We devised a method to determine the accuracy of a radiologist in identifying this important finding on CT scans in patients with blunt abdominal trauma. We retrospectively reviewed 50 CT scans and the radiologist’s report in patients who had undergone diagnostic peritoneal lavage (DPL) before the CT scan. We analyzed the report to see whether either free intraperitoneal air or the possibility of DPL was mentioned. Thirty scans retrospectively demonstrated free intraperitoneal air. The radiologist detected this finding in 25 patients (83%). In 5 patients (17%), the radiologist did not detect the free air or raise the possibility of a previous lavage. The amount of air introduced postlavage was variable, depending on the surgical technique and the time interval between the lavage and the CT scan. Air was most often demonstrated (in order of frequency) anterior to the liver, in the rectus recesses adjacent to the lavage defect, and in the fissures of the liver. In the five patients in whom free air was not identified, the amount or location of the air did not contribute to the error. The findings of this study were reviewed with all of the radiologists at a physician quality assurance meeting. A follow-up study of 25 patients was then obtained, and free air was detected in 25 (100%) of the cases. In summary, (a) free intraperitoneal air was missed in 17% of patients; (b) air preferentially collects beneath the diaphragm and in the rectus recesses; (c) there was no correlation between the amount or location of air and the error rate; (d) the most important variable is the examiner’s experience, and this can be improved markedly through education.     

Rupture of the pericardium with luxation of the heart after blunt trauma

This report describes a patient who presented to our hospital in stable condition without signs of circulatory or respiratory failure following previous surgery for blunt abdominal trauma. The diagnosis of rupture of the pericardium with luxation of the heart was suggested on chest X-ray and CT. Left anterior thoracotomy revealed a 6-cm longitudinal left pericardial tear with herniation of the heart into the mediastinum.     

Necrotizing fasciitis secondary to perforated sigmoid colon diverticulitis: Computed tomographic demonstration

We report a case of necrotizing fasciitis of the abdominal wall secondary to perforated sigmoid colon diverticulitis. Management consisted of immediate debridement of necrotic tissue, exploratory laparotomy, sigmoid and left hemicolectomy, and colostomy. Computed tomography played a critical role in this case by demonstrating diverticulitis and obstruction of the sigmoid colon as the underlying cause of the disease and the presence as well as extent of necrotizing fasciitis. Although rare, gastrointestinal tract pathology should be considered as a potential etiology of necrotizing fasciitis of the abdominal wall in patients without a history of abdominal wall trauma or surgery.     

Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients

In the US and Western Europe, trauma is the fourth most common cause of death and the leading cause of death in the population less than 45 years of age [Mullinix and Foley, J Comput Assist Tomogr 28(Suppl 1):S20–S27, 2004]. Diaphragmatic injuries occur in 0.8 to 8% of patients after blunt trauma (Gray H, The muscles of the thorax. Anatomy of the human body. Lea & Febiger, Philadelphia, 1918) and may be a predictor of severity of injury in the blunt trauma patient [Worthy et al., Radiology 194(3):885–888, 1995]. The clinical diagnosis of diaphragmatic rupture (DR) is difficult and is missed in anywhere from 7 to 66% of patients [Cantwell, Radiology 238(2):752–753, 2006]. The accurate diagnosis and prognosis of this pathology depend on a complete knowledge of the clinical and radiological presentation. Computed tomography is the imaging modality of choice in the assessment of patients with clinical or radiographic findings suggestive of DR.     

Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review of 12 cases

AIM: To determine the usefulness of multidetector-row CT (MDCT) with multiplanar reformatted (MPR) images in the sagittal and coronal plane in diagnosing acute right hemidiaphragmatic rupture. MATERIALS AND METHODS: Twelve patients were identified who received chest and abdominal MDCT after major blunt trauma diagnosed with right diaphragmatic injury. Sagittal and coronal reformations were performed in all cases. The images were retrospectively reviewed by two experienced radiologists for signs of right diaphragm injury, such as direct diaphragm discontinuity, the "collar sign", the "dependent viscera sign", and intra-thoracic location of herniated abdominal contents. RESULTS: Of the 12 cases of right hemidiaphragm rupture, diaphragm discontinuity was seen in seven (58%) cases, the collar sign in five (42%), the dependent viscera sign in four (33%), and transdiaphragmatic herniation of the right colon and fat in another. Two variants of the collar sign were apparent on high-quality sagittal and coronal reformations. The first, termed the "hump sign", describes a rounded portion of liver herniating through the diaphragm forming a hump-shaped mass, and the second, termed the "band sign," is a linear lucency across the liver along the torn edges of the hemidiaphragm. The hump sign occurred in 10 (83%) patients and the band sign in four (33%). CONCLUSION: MDCT is very useful in the diagnosis of right hemidiaphragm injury caused by blunt trauma when sagittal and coronal reformatted images are obtained, and should allow more frequent preoperative diagnosis.     

The role of computed tomography in the diagnosis and management of clinically occult post-traumatic small bowel perforation

PurposeTo evaluate the use of computed tomography [CT] in the diagnosis of occult post-traumatic small bowel perforation and to discuss the role of CT in the management of this patient group.MethodThis review includes three patients who presented with mild abdominal symptoms following minor blunt abdominal trauma. Initial radiographs and laboratory investigations were unremarkable but their symptoms failed to resolve and contrast-enhanced CT was performed for further evaluation.ResultsIn each case the CT appearances were indicative of localised small bowel perforation, with no evidence of other visceral injury. In two patients pockets of free intraperitoneal air were present closely related to the second part of the duodenum suggesting injury at this site. In the third case, a thickened proximal jejunal loop was demonstrated with free air and fluid in the adjacent mesentery consistent with a focal perforation. These CT findings were subsequently confirmed at laparotomy.ConclusionCT is an accurate diagnostic tool in the assessment of clinically and radiologically occult traumatic small bowel injury. The use of CT should be considered in patients who have unresolving abdominal symptoms even after apparently insignificant abdominal trauma.     

Computed tomographic diagnosis of septic sinus thrombosis and their complications

Summary The authors report on five cases of septic sinus thrombosis occurring as early complications and/or long-term complications of infections in the head and neck region. The necessity for early diagnosis of this condition by high-resolution CT scanning is emphasized, as it provides a reliable diagnostic tool to evaluate this serious intracranial disease at a relatively early stage, provided an intravenous contrast medium is used. Although MRI represents an interesting new technique in the assessment of intracranial pathology, it cannot be routinely carried out during the acute phase of this condition due to metal life-support systems near the patient.     

Computed tomographic diagnosis of partial small bowel obstruction secondary to anterior peritoneal adhesions: relevance to laparoscopic cholecystectomy

A case is reported of partial small bowel obstruction secondary to anterior peritoneal adhesions which resulted in inadvertent trocar perforation of the small bowel at laparoscopic cholecystectomy. Careful assessment of computed tomographic examinations performed for acute abdominal complaints should include diagnosis of lower grades of small bowel obstruction from peritoneal adhesive disease. Laparoscopic surgeons should be apprised of peritoneal adhesions of bowel at usual sites of needle or trocar puncture.     

Small bowel imaging- a rapidly changing field and a challenge to radiology

There was a time when the small bowel follow-through (SBFT) was the primary method of diagnosing diseases of the small intestine. Enteroclysis was reinvented in the 70's and with the SBFT remained the dominant methods of investigating the mesenteric small intestine to the late 90's. Since the introduction of the first commercial computed tomography (CT) scanner in 1973, the ability of monoslice CT to diagnose different causes of intestinal obstruction and inflammatory bowel diseases emerged. The introduction of helical CT technology in 1989 and subsequently multichannel CT further changed small bowel imaging. Faster asquisition of a large volume of data with thinner collimation allowed multiplanar reformatting a distinct advantage in evaluating an organ which is longer than wide. The introduction of magnetic resonance (MR) imaging with its increased soft tissue contrast, lack of ionizing radiation, and the ability to acquire ultrafast sequences has made MR imaging an important tool in small bowel imaging (1). “The Times They Are A-Changin” Bob Dylan     

The dangling diaphragm sign: sensitivity and comparison with existing CT signs of blunt traumatic diaphragmatic rupture

The objectives of our study were to describe a new CT sign of diaphragmatic injury, the “dangling diaphragm” sign, and assess its comparative utility relative to other signs in the diagnosis of diaphragmatic injury resulting from blunt trauma. CT scans of 16 blunt trauma patients (12 men and four women, mean age 36.6 years old) with surgically proven diaphragmatic injury and 32 blunt trauma patients (24 men and eight women; mean age 37.4 years old) without evidence of diaphragmatic injury at surgery were blindly reviewed by three board certified radiologists specializing in body imaging. Studies were evaluated for the presence of established signs of diaphragmatic injury, as well as the dangling diaphragm sign, in which the free edge of the torn hemidiaphragm curls inward from its normal course parallel to the body wall. The sensitivity and specificity of each sign were determined, as were the correlation between the signs and the interobserver agreement in evaluation of these findings. The radiologists’ overall impression as to whether rupture was present was also recorded. In select cases, coronal and/or sagittal reformatted images were available, and they were reviewed following evaluation of the original axial images. Any change in interpretation due to these images was noted. The sensitivity of the radiologists’ overall impression for detection of diaphragmatic injury was 77%, with 98% specificity. Individual signs of diaphragmatic injury had sensitivities ranging from 44% to 69%, with specificities of 98% to 100%. The dangling diaphragm sign had a sensitivity of 54% and a specificity of 98%, similar to the other signs. Multiple signs were present in most cases of diaphragmatic injury, and coronal and sagittal reformatted images had little impact. Diaphragmatic injury remains a challenging radiographic diagnosis. The dangling diaphragm is a conspicuous sign of diaphragmatic injury, and awareness of it may increase detection of diaphragmatic injury on CT studies.     

Gastric pneumatosis and portal vein gas: incidental findings at helical CT after blunt abdominal trauma

Gastric pneumatosis is a rare form of intestinal pneumatosis related to a wide range of abnormalities, which by itself may not engender adverse consequences. Portal vein gas, on the other hand, has traditionally been regarded as a life-threatening condition associated with mesenteric ischemia and immediate surgery; however, recent observations have demonstrated a greater spectrum of etiologies associated with portal vein gas in which the prognosis seems to be more favorable and surgery is not necessary. We report the case of a 42-year-old man who developed gastric pneumatosis and portal vein gas after major abdominal trauma. The patient was conservatively treated. Follow-up CT performed 4 days later revealed that portal vein gas and gastric pneumatosis had resolved spontaneously.     

Small bowel obstruction due to a paracecal hernia: computerized tomography diagnosis

The role of computerized tomography (CT) in evaluating patients with small bowel obstruction (SBO) has been extensively described in the current literature. We report a rare case of SBO related to a surgically proven paracecal hernia, diagnosed on an abdominal CT scan preoperatively.