•BBMI occurred in 45 patients (28%). CT showed 37 cases having associated mesenteric injuries.
•The mean age was 33 yrs, and 82 % were male.
•78 % of patients had CT done within 12 hrs of the trauma.
•The major cause of BBMI in our study was RTA (76%).
BBMI AND CT FINDIGNS CORRELATION:
•Extraluminal air and oral contrast material and intramural air were virtually pathognomonic of bowel injury. However they were occasionally seen.
•Thickened bowel wall though subjective was useful sign that indicated not only bowel but also mesenteric injury.
•Mesenteric infiltration or “stranding” was found to be associated with mesenteric injury with or without bowel perforation, but in presence of associated bowel-wall thickening stranding was highly suggestive of significant bowel injury.
•CT diagnosed bowel perforation with a sensitivity of 95%, a specificity of 100%, and negative and positive predictive accuracies of 98.2% and 100%, respectively.
•CT diagnosed mesenteric injury with a sensitivity of 88%, a specificity of 100%, and negative and positive predictive accuracies of 95.9% and 100%, respectively.
Follow-up abdominal sonography was performed in all the 45 patients and abdominal CT scans was done in 11 (24%) patients.
PREDICTIVE VALUE OF INDIVIDUAL CT FINDINGS:
CT FEATURE | SENSITIVITY% | SPECIFICITY% | PPV% | NPV% |
Extraluminal oral contrast | 15 | 100 | 100 | 75 |
Extraluminal air contrast | 48 | 100 | 100 | 88 |
Focal or diffuse bowel wall thickening | 62 | 98 | 90 | 93 |
Wall discontinuity | 46 | 98 | 90 | 80 |
Mesenteric stranding with bowel wall thickening | 35 | 99 | 93 | 88 |
Abnormal bowel wall enhancement | 25 | 95 | 92 | 84 |
Mesenteric hematoma | 31 | 98 | 87 | 80 |
Fluid between aorta and IVC | 11 | 91 | 93 | 75 |
CORRELATION WITH PREVIOUS STUDIES
CT FEATURE | Present study | Brofman et al (2006)269 | Scaglione et al (2004)270 | Hanks et al (2003)271 | Brody et al (2000)191 | Breen et al (1997)272 | Dowe et al (1997)183 | Hagiwara et al (1995)173 |
Mesenteric stranding with bowel wall thickening | 35 , 99 | p < 0.05 | p < 0.05 | - | 44 , 100 | 77 , - | P <0.05 | 69 , 100% |
Abnormal bowel wall enhancement | 25 , 95 | p < 0.05 | - | - | - | | P <0.05 | |
Mesenteric hematoma | 31 , 98 | p < 0.05 | p < 0.05 | p < 0.05 | - | 54 , 94 | | |
Fluid between aorta and IVC | 11 , 91 | p < 0.05 | p < 0.05 | - | - | P<0.001 | | |
CT FEATURE | Present study | Brofman et al (2006)269 | Scaglione et al (2004)270 | Hanks et al (2003)271 | Brody et al (2000)191 | Breen et al (1997)272 | Sherck et al (1994)172 |
Extraluminal oral contrast | 15 ,100 | p < 0.05 | p < 0.05 | - | - | - | p < 0.05 |
Extraluminal air | 48 , 100 | p < 0.05 | p < 0.05 | p < 0.05 | 44 , 100 | - | p < 0.05 |
Focal or diffuse bowel wall thickening | 62 , 98 | p < 0.05 | p < 0.05 | - | 75 , 92 | 50 , 84 | - |
Wall discontinuity | 46 , 98 | p < 0.05 | p < 0.05 | - | - | 58 , 95 | p < 0.05 |
MANAGEMENT:
OUTCOME | BBMI |
RECOVERED | 41 (91%) |
DETERIORATED ON CONSERVATIVE | 8 (18%) |
DIED | 4 (9%) |
•Nonoperative management of BBMI was the modality of choice in patients with grade I injury.
•Nonoperative management was successfully applied to all patients with 85 % of grade I, 17 % of grade II, 0% of grade III and IV, and 8% of grade V bowel injuries.
•18 (85.7%) of 21 cases were successfully managed conservatively.
•Three cases (14%) of grade I injury had failed conservative management and were taken up for delayed laparotomy.
•All the grade III and IV injuries underwent surgical repair.
•Of the 5cases of grade V injury one was managed conservatively.
NEED FOR SURGERY CORRELATION:
CRITERION | ODDS RATIO | CONFIDENCE LIMITS (95%) | KAPPA | P VALUE |
AAST | 11.2 | 2.1 | 115.9 | 0.435 | 0.002 |
PNEUMOPERITONEUM | 29.4 | 3.3 | 255.9 | 0.629 | < 0.0001 |
LACERATION | 14.2 | 1.6 | 124.6 | 0.335 | 0.004 |
WALL THICKENING | 0.024 | 0.004 | 0.130 | - 0.726 | < 0.0001 |
WALL ENHANCEMENT | 19.0 | 3.5 | 102.5 | 0.561 | <0.0001 |
CRITERION | Present study | Scaglione et al (2004)270 | Killeen et al (2002)273 | Frick et al (1999)277 | Ciftci et al (1998)21 | Rizzo et al (1989)184 |
AAST grade | P = 0.002 | P < 0.05 | P < 0.05 | - | P < 0.05 | P < 0.05 |
Laceration | P = 0.004 | P < 0.05 | - | P < 0.05 | - | - |
Pneumoperitoneum | P <0.0001 | P < 0.05 | - | P < 0.05 | - | P < 0.05 |
Wall thickening | P <0.0001 | - | - | P < 0.05 | - | P < 0.05 |
Wall enhancement | P <0.0001 | - | - | - | - | P < 0.05 |
CRITERION | Present study | Scaglione et al (2004)270 | Hanks et al (2003)271 | Frick et al (1999)277 | Rizzo et al (1989)184 |
Mesenteric Streaking | 0.003 | - | - | - | P < 0.05 |
Mesenteric Hematoma | P < 0.05 | - | P < 0.05 | - | P < 0.05 |
Mesenteric Air | P < 0.05 | P < 0.05 | - | P < 0.05 | P < 0.05 |
Active hemorrhage | < 0.0001 | P < 0.05 | - | - | - |
RARE FINDINGS | NO OF CASES |
FLUID BETWEEN IVC AND AORTA | 9 |
SHOCK BOWEL | 9 |
MALIGNANT STRICTURE WITH BOWEL INJURY | 1 |
EXTRALUMINAL FECES | 1 |
FECAL PERITONITIS | 1 |