Pediatric Bowel Trauma

  • Etiology: Blunt abdominal trauma
  • Imaging CT: CT with IV contrast and with or without oral contrast is study of choice but can be difficult to diagnose
    — Small bowel most common
    — Focal or multifocal bowel wall thickening and enhancement
    — Focal bowel wall thickening with adjacent fluid present which should raise suspicion for sealed perforation
    — Stranding of fat adjacent to bowel
    — Localized large intramural hematoma – duodenum most common
    — Moderate volume free intraperitoneal fluid or hemoperitoneum with unexplained source and no solid organ injury
    — Small locules of free air
    — Pneumoretroperitoneum from duodenal injury, extravasation of oral contrast
    — Mesenteric edema and contusion
    — Fluid at mesenteric root
    — Focal bowel wall defect
    — Active hemorrhage
    — Mesenteric pseudoaneurysm
  • Note: If initial CT is negative and abdominal pain persists, repeat CT at 24 hours to look for increasing amount of free intraperitoneal fluid
  • Note: Fluid in mesentery should be considered finding of bowel injury
  • Note: Pitfall is mesenteric laceration can result in free fluid
  • Note: Mesenteric lacerations are difficult to diagnose on imaging
  • DDX:
  • Complications:
  • Treatment: Injuries often requiring surgical intervention:
    — Full thickness bowel injury
    — Moderate volume peritoneal fluid or hemoperitoneum with unclear source and no solid organ injury
    — Pneumoperitoneum
    — Pneumoretroperitoneum
    — Focal bowel wall defect
    — Extravasated oral contrast
    — Active hemorrhage
    — Mesenteric pseudoaneurysm
  • Clinical:
    — In 1-3% of trauma patients
    — Commonly associated with lap belt ecchymoses and handlebar injuries

Radiology Cases of Bowel Trauma

CT of bowl trauma / bowel perforation
Initial axial CT with contrast of the abdomen (left images) shows no solid organ injury but a moderate amount of free fluid in the abdomen and pelvis. Repeat axial CT with contrast of the abdomen obtain a day later due to increasing abdominal pain (right images) shows a marked increase in the free fluid within the abdomen and pelvis.

Radiology Cases of Jejunal Perforation

CT of jejunal perforation
Axial CT with intravenous and oral contrast of the abdomen from the day of admission (above) shows a small amount of free fluid in the pelvis. There was no evidence of solid organ injury or free air. Repeat CT with intravenous and oral contrast from one day later due to increasing abdominal pain (below) shows a marked increase in the amount of free fluid present.

Radiology Cases of Ileal Perforation

CT of ileal perforation
Axial CT with contrast of the abdomen from the day of admission (above) shows no solid organ injury, no free air and no free fluid in the pelvis. Axial CT with contrast of the abdomen obtained 24 hours later due to a worsening abdominal exam (below) shows new free fluid in the pelvis and no evidence of free air.

Surgery Cases of Bowel Trauma

Surgical image of small bowel perforation
Surgical image shows an ileal perforation with the forceps placed through the perforation.