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Isolated mesenteric injury due to blunt abdominal trauma
Injury, 7, 295-298
295
Isolated mesenteric injury due to blunt abdominal trauma C. J. McCullough Surgical Registrar. Royal Gwent Hospital Summary Isolated injuries of the small bowel mesentery or mesocolon with subsequent bowel infarction due to blunt abdominal trauma are rare. Two cases are described: 1 involving the mesentery to the terminal ileum and 1 involving the transverse mesocolon and middle colic artery, both with bowel infarction. The modes of clinical presentation and management of patients with injuries to the mesentery, mesocolon and mesenteric vessels following blunt trauma are described.
INTRODUCTION INJURIES o f t h e small bowel a n d its mesentery, a l t h o u g h c o m m o n l y associated with p e n e t r a t i n g a b d o m i n a l injury, are r a r e following b l u n t t r a u m a to t h e a b d o m e n . S u c h injuries f o r m approxim a t e l y 5-10 per cent o f all cases o f i n t r a - a b d o m i nal injury s e c o n d a r y to n o n - p e n e t r a t i n g t r a u m a in m o s t series (Orloff a n d Charters, 1972). I s o l a t e d injury o f t h e mesentery, however: is rare. I n a r e c e n t series o f 59 consecutive cases o f b l u n t a b d o m i n a l injury t h e r e were 6 cases o f mesenteric injury: 5 cases were associated with small bowel injury, b u t only 1 was a case o f isolated m e s e n t e r i c injury ( B o l t o n et al., 1973). I n r o a d traffic a c c i d e n t victims w h o were wearing seat belts, the j e j u n u m a n d i l e u m with t h e i r m e s e n t e r y are t h e m o s t frequently d a m a g e d i n t r a - a b d o m i n a l structures. A l t h o u g h the wearing o f seat belts h a s r e d u c e d t h e incidence o f serious injury f r o m 30 to 0"7 p e r cent ( G a r r e t t a n d B r a u n s t e i n , 1962), 25 o u t o f 32 p a t i e n t s w h o h a d suffered i n t r a - a b d o m i n a l injury while wearing seat belts h a d d a m a g e to t h e small bowel or its m e s e n t e r y ( M a c L e o d a n d N i c h o l s o n , 1969). Injuries to t h e c o l o n c o n s t i t u t e 3-5 p e r cent of all i n t r a - a b d o m i n a l injuries s e c o n d a r y t o b l u n t t r a u m a . T h e force r e q u i r e d to d a m a g e t h e c o l o n
is c o n s i d e r a b l e and, therefore, the incidence o f a s s o c i a t e d i n t r a - a b d o m i n a l injuries is h i g h ( M c K e n z i e a n d Bell, 1972). Isolated injury to t h e m e s o c o l o n is rare.
CASE REPORTS Case I A 39-year-old man was admitted to the Royal Gwent Hospital having been involved in a road traffic accident. He had been drinking heavily, was the driver of the car and had not been wearing a seat belt. He remembered having struck his chest and abdomen on the steering wheel of his car on impact. He had not been unconscious and on admission complained of left lower anterior chest pain. On examination, his blood pressure was 110/80 m m Hg and his pulse rate was 90. There was tenderness over the anterolateral part of the left side of his chest but good overall air entry. His abdomen was soft and bowel-sounds were normal. He had superficial facial lacerations. Chest X-ray revealed a fracture of the left seventh rib. Ten hours after admission he complained of left upper abdominal pain. His pulse rate had risen to 110 and his blood pressure to 190/130ram Hg. There was localized tenderness in the left hypochondrium with no rebound tenderness and the bowel-sounds were quiet. Twelve hours after admission his left hypochondrial tenderness had increased and rebound tenderness was evident. His pulse rate had risen to 125 and he was now pyrexial. Laparotomy was undertaken through an upper mid-line incision. A vertical rent was found in the transverse mesocolon, and the middle colic artery had been severed and was in spasm. The middle 10 cm of the transverse colon was gangrenous. The middle colic artery was ligated and the defect in the transverse mesocolon repaired. The gangrenous segment was exteriorized and resected via a separate incision in the left hypochondrium and a double-barrelled colostomy fashioned. He was then treated with nasogastric suction, intravenous liquids and parenteral gentamicin and Iincomycin. He made a
296
Injury: the British Journal of Accident Surgery Vol. 7/No. 4
satisfactory postoperative recovery despite a chest infection. He was subsequently admitted for extraperitoneal closure of the colostomy, which was performed without complication. He was discharged finally from hospital 8 weeks after sustaining his original injury. Case 2
A 39-year-old driver of an articulated lorry was injured when his lorry jack-knifed. He was not wearing a seat belt and he remembers the steering wheel striking his abdomen. On admission he complained of lower abdominal pain. On examination his blood pressure was 140/90 mm Hg, his pulse rate was 70 and his temperature, 37 ~ There was slight tenderness in the right iliac fossa but no rebound tenderness and his bowel-sounds were normal. There were no associated injuries. Twelve hours after admission he had persistent localized tenderness in the right iliac fossa but no sign of peritoneal irritation. His pulse rate had risen to 90 and he was pyrexial. Twenty hours after admission the abdominal signs were unchanged and the patient said he felt better. Forty-eight hours after his injury his temperature rose to 38 ~ and his pulse rose to 100. Signs of lower abdominal peritoneal irritation were present with associated abdominal distension. At laparotomy there was heavily bloodstained liquid in the abdomen. There were two transverse tears in the mesentery of the terminal ileum and two adjacent gangrenous segments of ileum measuring 15 cm in length. There was a small tear on the under surface of the right lobe of the liver that was not bleeding. A right hemicolectomy was performed with end-to-end ileocolic anastomosis. The peritoneum was drained and antibiotic therapy initiated with Ceporin. After operation he had a prolonged ileus requiring intravenous fluids and nasogastric suction for 6 days. Subsequently he made a good and uneventful recovery and was discharged home 17 days after operation.
DISCUSSION M e c h a n i s m of injury The bowel or its mesentery may be injured by compression between an external force and the lordotic lumbar spine. Nowadays the external force is usually the rim of a steering wheel or the lap-strap of a seat belt. A shearing force may also injure the bowel and its mesentery, most commonly at the junction between its fixed and mobile parts. The lap-strap of a seat belt is particularly incriminated in this form of injury; a loosely adjusted seat belt allows the car occupant to slide forwards and downwards following a collision, and thus the lap-strap impinges on the abdominal viscera and not on the pelvis as intended (Shennan, 1973b). Both of the patients here described were not wearing seat belts and both gave a definite history of the steering wheel striking the abdomen.
Clinical presentation The clinical presentation of isolated mesenteric injuries may be categorized as: 1. Immediate, due to bleeding. 2. Delayed, due to bowel infarction with subsequent perforation. 3. Late, due to bowel stenosis or adhesion formation. Immediate Acute bleeding may occur from the small mesenteric vessels, and signs of intraperitoneal blood loss make early laparotomy imperative. Definitive treatment is control of haemorrhage, resection of any non-viable bowel and closure of the mesenteric defect. Injuriesto the main mesenteric vessels resulting in acute haemorrhage are rare. There are seven reported cases of injury to the superior mesenteric vessels secondary to blunt abdominal trauma which are reviewed by Killen (1964). In all cases, the superior mesenteric vein was damaged, and in 4 cases there was associated injury of the superior mesenteric artery. Operative reconstruction of the damaged vessels is essential to save life (Ulvestad, 1954). Fistula formation between the superior mesenteric artery and vein has been reported following penetrating wounds (Hunt, 1971), with resultant small bowel ischaemia, but not following blunt trauma. Delayed Bowel infarction may result from either mesenteric tears with disruption of blood vessels or mesenteric vessel thrombosis, either venous or arterial. In the absence of intraperitoneal bleeding, early abdominal signs and symptoms may be minimal. Both our patients developed localized abdominal pain and tenderness within a few hours of injury. This tenderness was persistent on repeated examination, but it was 12 hours (Case 1) and 48 hours (Case 2) before signs of peritoneal irritation developed. It is suggested that persistent localized tenderness in the absence of other signs should be sufficient indication for laparotomy, particularly if there is a history of a direct blow to the abdomen. Difficulties in interpreting the physical sign of tenderness may be found if there is associated abdominal wall trauma, as if often encountered in the seat-belt syndrome (Doersch and Dosjev, 1968), or injury to the lower chest o r pelvis. Two cases of delayed perforation of the small bowel secondary to blunt trauma by a seat belt have been described in which the interval between injury and laparotomy was 48 hours and 5
McCullough: IsolatedMesentericInjury
days respectively (Porter and Green, 1968). Delayed ischaemic perforation of the colon as part of the seat-belt syndrome (Shennan, 1973a) or secondary to other blunt trauma (Wightman, 1967) is now well recognized. The pathological process described is the formation of an intramural haematoma with necrotizing trauma to the mucosa. However, in a recent case report (Jaeck et al., 1972) delayed colonic rupture has been shown to occur secondary to mesocolon injury. In this case, a 57-year-old man sustained blunt abdominal trauma following a fall on his left flank. At laparotomy, undertaken within a few hours of injury, a perforation of the proximal jejunum was repaired and a haematoma was found in the sigmoid mesocolon adjacent to the bowel. The sigmoid colon was considered viable but a drain was laid along the paracolic gutter. Five days after operation a colonic fistula developed along the drain. At laparotomy the colon was found to have perforated at the level of the damaged mesocolon and it was therefore exteriorized and resected. A similar case was reported by Blumenberg (1967) in which the interval from injury to laparotomy was 72 hours. If the colon perforates retroperitoneally, a colocutaneous fistula may occur several days or weeks after injury (Wightman, 1967). Mesenteric arterial thrombosis secondary to blunt trauma has been reported by several authors (Pontius et al., 1956; Mathieson, 1962). Thromboses of the ileocolic, middle colic and inferior mesenteric arteries have been described. The interval between injury and laparotomy was between 24 hours and 100 hours. Mesenteric venous thrombosis secondary to blunt abdominal trauma has been reviewed by McCune et al. (1952). The problems associated with this rare injury have been summarized as follows. The rate of propagation of thrombus is variable and, therefore, the resultant bowel infarction may occur within a few hours of injury but may be delayed for up to 5 weeks. Following resection of the infarcted segment, an extension of the gangrenous process may occur due to propagation of thrombus. Separate thrombi in different parts of the venous mesenteric bed may extend at different rates, producing infarction at varying intervals after injury. Thus, following bowel resection for infarction secondary to mesenteric vessel thrombosis due to trauma, additional procedures including thrombectomy or splanchnic nerve block should be considered, though the use of anticoagulants is not recommended (Orloff and Charters, 1972).
297 Late
Three cases are described of stenosis of the terminal ileum secondary to mesenteric damage (Urban, 1968; Taylor, 1971; Jaeck et al., 1972). The patients all sustained blunt trauma to the abdomen and developed symptoms and signs of incomplete small bowel obstruction which required laparotomy between 5 and 8 weeks after injury. In 2 cases, organized haematomas were found in the mesentery adjacent to stenotic segments of small bowel. Histology of the bowel revealed ulcerated mucosa, transmural chronic inflammation with submucosal granuloma formation, oedema and fibrosis. Treatment was by resection of the stenotic segment. Stenosis of the sigmoid colon of similar aetiology has been described (Altner, 1964). Local damage to the colonic wall is also responsible for posttraumatic strictures, because in certain cases arteriography has revealed normal vasculature in the mesocolon (Corbett, 1957). Adhesion formation secondary to mesenteric peritoneal damage, causing intermittent small bowel obstruction at the terminal ileum following blunt trauma, has been reported (Kulowski and Rost, 1956). The interval between injury and subsequent laparotomy was 4 months.
CONCLUSION The difficulties associated with the diagnosis of isolated mesenteric injury occur in those cases where mesenteric damage is sufficient to render the bowel non-viable. In the absence of haemorrhage, early abdominal signs and symptoms may be minimal. The combination of a history of a direct blow to the abdomen and persistent localized abdominal tenderness should be sufficient indication for exploratory laparotomy. Even at laparotomy, great care must be taken in assessing the viability of the bowel when a mesenteric haematoma adjacent to the bowel is present. The haematoma forms as a result of damage to the small mesenteric vessels, which may be sufficiently severe to render the adjacent bowel ischaemic and result in delayed bowel perforation or stenosis. If the viability of the bowel is in doubt, resection of the affected segment of small bowel or exteriorization of involved large bowel should be undertaken.
Acknowledgement I would like to thank Mr L. P. Thomas, consultant surgeon, for permission to publish the case reports of patients under his care and also for his helpful criticism in the writing of this paper.
298 REFERENCES
ALTNER P. C. (1964) Constrictive lesions of the colon due to blunt trauma to the abdomen. Surg. GynecoL Obstet. 118, 1257. BLUMENBERG R. M. (1967) The seat-belt syndrome: sigmoid colon perforation. Ann. Surg. 165, 637. BOLTON P. M., Wood C. B., QUARTEY-PAPAFIO J. B. and BLUMGART L. H. (1973) Blunt abdominal injury--a review of 59 consecutive cases undergoing surgery. Br. J. Surg. 60, 657. CORBETTT R. (1957) Stenosed segment of descending colon associated with trauma. Proc. R. Soc. Ned. 50, 271. DOERSCH K. B. and DOSJEV W. E. (1968) The seat-belt syndrome. The seat-belt sign; intestinal and mesenteric injuries. Am. J. Surg. 116, 831. GARRETT J. W. and BRAUNSTEIN P. W. (1962) The seat-belt syndrome. J. Trauma 2, 220. HUNT T. K. (1971) Arteriovenous fistula of major vessels in the abdomen. J. Trauma 11, 483. JAECK D., THOMAS M., DAUCHEL J. and SAVA G. (1972) A p r o p o s des complications des traumatismes du m6sent~re et du m6socolon sigmoide. Chirurgie 98, 437. KILLEN D. A. (1964) Injury of the superior mesenteric vessels secondary to non-penetrating abdominal trauma. Am. Surg. 30, 306. KULOWSKI J. and ROST W. B. (1956) Intra-abdominal injury from safety belt in auto accident. Arch. Surg. 73, 970. MATHIESON A. J. M. (1962) Closed abdominal injury. Br. Ned. J. 2, 749.
Injury : the British Journal of Accident Surgery Vol. 7/No. 4
McCuNE W. S., KESHISHIAN J. M. and BLADES B. B. (1952) Mesenteric thrombosis following blunt abdominal trauma. Ann. Surg. 135, 606. MCKENZIE A. D. and BELL G. A. (1972) Non-penetrating injuries of the colon and rectum. Surg. Clin. North Am. 52, 735. MAcL~oD J. H. and NICHOLSON D. M. (1969) Seat belt trauma to the abdomen. Can. J. Surg. 12, 202. ORLOFF M. J. and CHARTERS A. C. (1972) Injuries of the small bowel and mesentery and r e t r o peritoneal haematoma. Surg. Clin. North Am. 52, 729. PONTIUS G. V., KILBOURNE B. C. and PAUL E. G. (1956) Non-penetrating abdominal trauma. Arch. Surg. 72, 800. PORTER S. n . and GREEN E. W. (1968) Seat belt injuries. Arch. Surg. 96, 242. SHENNAN J. (1973a) The seat-belt syndrome. Br. J. Hosp. Ned. 10, 199. SHENNAN J. (1973b) Seat-belt injury to the colon. Br. J. Surg. 60, 673. TAYLOR F. W. (1971) Seat-belt injury resulting in 'regional enteritis' and intestinal obstruction. J A M A 215, 1154. ULVESTAD L. E. (1954) Repair of laceration of superior mesenteric artery acquired by nonpenetrating injury to the abdomen. Ann. Surg. 140, 752. URBAN C. H. (1968) Stenosis of ileum due to mesenteric laceration. J A M A 204, 178. WIGHTMANT. A. K. (1967) Delayed traumatic rupture of colon with colocutaneous fistula. Br. Ned. J. 2, 93.
Requestsfor reprintsshouldbe addressed to: C. J. McCullough, FRCS, 58 Windsor Road, Lawn, Swindon, SN3 1JX.
295
Isolated mesenteric injury due to blunt abdominal trauma C. J. McCullough Surgical Registrar. Royal Gwent Hospital Summary Isolated injuries of the small bowel mesentery or mesocolon with subsequent bowel infarction due to blunt abdominal trauma are rare. Two cases are described: 1 involving the mesentery to the terminal ileum and 1 involving the transverse mesocolon and middle colic artery, both with bowel infarction. The modes of clinical presentation and management of patients with injuries to the mesentery, mesocolon and mesenteric vessels following blunt trauma are described.
INTRODUCTION INJURIES o f t h e small bowel a n d its mesentery, a l t h o u g h c o m m o n l y associated with p e n e t r a t i n g a b d o m i n a l injury, are r a r e following b l u n t t r a u m a to t h e a b d o m e n . S u c h injuries f o r m approxim a t e l y 5-10 per cent o f all cases o f i n t r a - a b d o m i nal injury s e c o n d a r y to n o n - p e n e t r a t i n g t r a u m a in m o s t series (Orloff a n d Charters, 1972). I s o l a t e d injury o f t h e mesentery, however: is rare. I n a r e c e n t series o f 59 consecutive cases o f b l u n t a b d o m i n a l injury t h e r e were 6 cases o f mesenteric injury: 5 cases were associated with small bowel injury, b u t only 1 was a case o f isolated m e s e n t e r i c injury ( B o l t o n et al., 1973). I n r o a d traffic a c c i d e n t victims w h o were wearing seat belts, the j e j u n u m a n d i l e u m with t h e i r m e s e n t e r y are t h e m o s t frequently d a m a g e d i n t r a - a b d o m i n a l structures. A l t h o u g h the wearing o f seat belts h a s r e d u c e d t h e incidence o f serious injury f r o m 30 to 0"7 p e r cent ( G a r r e t t a n d B r a u n s t e i n , 1962), 25 o u t o f 32 p a t i e n t s w h o h a d suffered i n t r a - a b d o m i n a l injury while wearing seat belts h a d d a m a g e to t h e small bowel or its m e s e n t e r y ( M a c L e o d a n d N i c h o l s o n , 1969). Injuries to t h e c o l o n c o n s t i t u t e 3-5 p e r cent of all i n t r a - a b d o m i n a l injuries s e c o n d a r y t o b l u n t t r a u m a . T h e force r e q u i r e d to d a m a g e t h e c o l o n
is c o n s i d e r a b l e and, therefore, the incidence o f a s s o c i a t e d i n t r a - a b d o m i n a l injuries is h i g h ( M c K e n z i e a n d Bell, 1972). Isolated injury to t h e m e s o c o l o n is rare.
CASE REPORTS Case I A 39-year-old man was admitted to the Royal Gwent Hospital having been involved in a road traffic accident. He had been drinking heavily, was the driver of the car and had not been wearing a seat belt. He remembered having struck his chest and abdomen on the steering wheel of his car on impact. He had not been unconscious and on admission complained of left lower anterior chest pain. On examination, his blood pressure was 110/80 m m Hg and his pulse rate was 90. There was tenderness over the anterolateral part of the left side of his chest but good overall air entry. His abdomen was soft and bowel-sounds were normal. He had superficial facial lacerations. Chest X-ray revealed a fracture of the left seventh rib. Ten hours after admission he complained of left upper abdominal pain. His pulse rate had risen to 110 and his blood pressure to 190/130ram Hg. There was localized tenderness in the left hypochondrium with no rebound tenderness and the bowel-sounds were quiet. Twelve hours after admission his left hypochondrial tenderness had increased and rebound tenderness was evident. His pulse rate had risen to 125 and he was now pyrexial. Laparotomy was undertaken through an upper mid-line incision. A vertical rent was found in the transverse mesocolon, and the middle colic artery had been severed and was in spasm. The middle 10 cm of the transverse colon was gangrenous. The middle colic artery was ligated and the defect in the transverse mesocolon repaired. The gangrenous segment was exteriorized and resected via a separate incision in the left hypochondrium and a double-barrelled colostomy fashioned. He was then treated with nasogastric suction, intravenous liquids and parenteral gentamicin and Iincomycin. He made a
296
Injury: the British Journal of Accident Surgery Vol. 7/No. 4
satisfactory postoperative recovery despite a chest infection. He was subsequently admitted for extraperitoneal closure of the colostomy, which was performed without complication. He was discharged finally from hospital 8 weeks after sustaining his original injury. Case 2
A 39-year-old driver of an articulated lorry was injured when his lorry jack-knifed. He was not wearing a seat belt and he remembers the steering wheel striking his abdomen. On admission he complained of lower abdominal pain. On examination his blood pressure was 140/90 mm Hg, his pulse rate was 70 and his temperature, 37 ~ There was slight tenderness in the right iliac fossa but no rebound tenderness and his bowel-sounds were normal. There were no associated injuries. Twelve hours after admission he had persistent localized tenderness in the right iliac fossa but no sign of peritoneal irritation. His pulse rate had risen to 90 and he was pyrexial. Twenty hours after admission the abdominal signs were unchanged and the patient said he felt better. Forty-eight hours after his injury his temperature rose to 38 ~ and his pulse rose to 100. Signs of lower abdominal peritoneal irritation were present with associated abdominal distension. At laparotomy there was heavily bloodstained liquid in the abdomen. There were two transverse tears in the mesentery of the terminal ileum and two adjacent gangrenous segments of ileum measuring 15 cm in length. There was a small tear on the under surface of the right lobe of the liver that was not bleeding. A right hemicolectomy was performed with end-to-end ileocolic anastomosis. The peritoneum was drained and antibiotic therapy initiated with Ceporin. After operation he had a prolonged ileus requiring intravenous fluids and nasogastric suction for 6 days. Subsequently he made a good and uneventful recovery and was discharged home 17 days after operation.
DISCUSSION M e c h a n i s m of injury The bowel or its mesentery may be injured by compression between an external force and the lordotic lumbar spine. Nowadays the external force is usually the rim of a steering wheel or the lap-strap of a seat belt. A shearing force may also injure the bowel and its mesentery, most commonly at the junction between its fixed and mobile parts. The lap-strap of a seat belt is particularly incriminated in this form of injury; a loosely adjusted seat belt allows the car occupant to slide forwards and downwards following a collision, and thus the lap-strap impinges on the abdominal viscera and not on the pelvis as intended (Shennan, 1973b). Both of the patients here described were not wearing seat belts and both gave a definite history of the steering wheel striking the abdomen.
Clinical presentation The clinical presentation of isolated mesenteric injuries may be categorized as: 1. Immediate, due to bleeding. 2. Delayed, due to bowel infarction with subsequent perforation. 3. Late, due to bowel stenosis or adhesion formation. Immediate Acute bleeding may occur from the small mesenteric vessels, and signs of intraperitoneal blood loss make early laparotomy imperative. Definitive treatment is control of haemorrhage, resection of any non-viable bowel and closure of the mesenteric defect. Injuriesto the main mesenteric vessels resulting in acute haemorrhage are rare. There are seven reported cases of injury to the superior mesenteric vessels secondary to blunt abdominal trauma which are reviewed by Killen (1964). In all cases, the superior mesenteric vein was damaged, and in 4 cases there was associated injury of the superior mesenteric artery. Operative reconstruction of the damaged vessels is essential to save life (Ulvestad, 1954). Fistula formation between the superior mesenteric artery and vein has been reported following penetrating wounds (Hunt, 1971), with resultant small bowel ischaemia, but not following blunt trauma. Delayed Bowel infarction may result from either mesenteric tears with disruption of blood vessels or mesenteric vessel thrombosis, either venous or arterial. In the absence of intraperitoneal bleeding, early abdominal signs and symptoms may be minimal. Both our patients developed localized abdominal pain and tenderness within a few hours of injury. This tenderness was persistent on repeated examination, but it was 12 hours (Case 1) and 48 hours (Case 2) before signs of peritoneal irritation developed. It is suggested that persistent localized tenderness in the absence of other signs should be sufficient indication for laparotomy, particularly if there is a history of a direct blow to the abdomen. Difficulties in interpreting the physical sign of tenderness may be found if there is associated abdominal wall trauma, as if often encountered in the seat-belt syndrome (Doersch and Dosjev, 1968), or injury to the lower chest o r pelvis. Two cases of delayed perforation of the small bowel secondary to blunt trauma by a seat belt have been described in which the interval between injury and laparotomy was 48 hours and 5
McCullough: IsolatedMesentericInjury
days respectively (Porter and Green, 1968). Delayed ischaemic perforation of the colon as part of the seat-belt syndrome (Shennan, 1973a) or secondary to other blunt trauma (Wightman, 1967) is now well recognized. The pathological process described is the formation of an intramural haematoma with necrotizing trauma to the mucosa. However, in a recent case report (Jaeck et al., 1972) delayed colonic rupture has been shown to occur secondary to mesocolon injury. In this case, a 57-year-old man sustained blunt abdominal trauma following a fall on his left flank. At laparotomy, undertaken within a few hours of injury, a perforation of the proximal jejunum was repaired and a haematoma was found in the sigmoid mesocolon adjacent to the bowel. The sigmoid colon was considered viable but a drain was laid along the paracolic gutter. Five days after operation a colonic fistula developed along the drain. At laparotomy the colon was found to have perforated at the level of the damaged mesocolon and it was therefore exteriorized and resected. A similar case was reported by Blumenberg (1967) in which the interval from injury to laparotomy was 72 hours. If the colon perforates retroperitoneally, a colocutaneous fistula may occur several days or weeks after injury (Wightman, 1967). Mesenteric arterial thrombosis secondary to blunt trauma has been reported by several authors (Pontius et al., 1956; Mathieson, 1962). Thromboses of the ileocolic, middle colic and inferior mesenteric arteries have been described. The interval between injury and laparotomy was between 24 hours and 100 hours. Mesenteric venous thrombosis secondary to blunt abdominal trauma has been reviewed by McCune et al. (1952). The problems associated with this rare injury have been summarized as follows. The rate of propagation of thrombus is variable and, therefore, the resultant bowel infarction may occur within a few hours of injury but may be delayed for up to 5 weeks. Following resection of the infarcted segment, an extension of the gangrenous process may occur due to propagation of thrombus. Separate thrombi in different parts of the venous mesenteric bed may extend at different rates, producing infarction at varying intervals after injury. Thus, following bowel resection for infarction secondary to mesenteric vessel thrombosis due to trauma, additional procedures including thrombectomy or splanchnic nerve block should be considered, though the use of anticoagulants is not recommended (Orloff and Charters, 1972).
297 Late
Three cases are described of stenosis of the terminal ileum secondary to mesenteric damage (Urban, 1968; Taylor, 1971; Jaeck et al., 1972). The patients all sustained blunt trauma to the abdomen and developed symptoms and signs of incomplete small bowel obstruction which required laparotomy between 5 and 8 weeks after injury. In 2 cases, organized haematomas were found in the mesentery adjacent to stenotic segments of small bowel. Histology of the bowel revealed ulcerated mucosa, transmural chronic inflammation with submucosal granuloma formation, oedema and fibrosis. Treatment was by resection of the stenotic segment. Stenosis of the sigmoid colon of similar aetiology has been described (Altner, 1964). Local damage to the colonic wall is also responsible for posttraumatic strictures, because in certain cases arteriography has revealed normal vasculature in the mesocolon (Corbett, 1957). Adhesion formation secondary to mesenteric peritoneal damage, causing intermittent small bowel obstruction at the terminal ileum following blunt trauma, has been reported (Kulowski and Rost, 1956). The interval between injury and subsequent laparotomy was 4 months.
CONCLUSION The difficulties associated with the diagnosis of isolated mesenteric injury occur in those cases where mesenteric damage is sufficient to render the bowel non-viable. In the absence of haemorrhage, early abdominal signs and symptoms may be minimal. The combination of a history of a direct blow to the abdomen and persistent localized abdominal tenderness should be sufficient indication for exploratory laparotomy. Even at laparotomy, great care must be taken in assessing the viability of the bowel when a mesenteric haematoma adjacent to the bowel is present. The haematoma forms as a result of damage to the small mesenteric vessels, which may be sufficiently severe to render the adjacent bowel ischaemic and result in delayed bowel perforation or stenosis. If the viability of the bowel is in doubt, resection of the affected segment of small bowel or exteriorization of involved large bowel should be undertaken.
Acknowledgement I would like to thank Mr L. P. Thomas, consultant surgeon, for permission to publish the case reports of patients under his care and also for his helpful criticism in the writing of this paper.
298 REFERENCES
ALTNER P. C. (1964) Constrictive lesions of the colon due to blunt trauma to the abdomen. Surg. GynecoL Obstet. 118, 1257. BLUMENBERG R. M. (1967) The seat-belt syndrome: sigmoid colon perforation. Ann. Surg. 165, 637. BOLTON P. M., Wood C. B., QUARTEY-PAPAFIO J. B. and BLUMGART L. H. (1973) Blunt abdominal injury--a review of 59 consecutive cases undergoing surgery. Br. J. Surg. 60, 657. CORBETTT R. (1957) Stenosed segment of descending colon associated with trauma. Proc. R. Soc. Ned. 50, 271. DOERSCH K. B. and DOSJEV W. E. (1968) The seat-belt syndrome. The seat-belt sign; intestinal and mesenteric injuries. Am. J. Surg. 116, 831. GARRETT J. W. and BRAUNSTEIN P. W. (1962) The seat-belt syndrome. J. Trauma 2, 220. HUNT T. K. (1971) Arteriovenous fistula of major vessels in the abdomen. J. Trauma 11, 483. JAECK D., THOMAS M., DAUCHEL J. and SAVA G. (1972) A p r o p o s des complications des traumatismes du m6sent~re et du m6socolon sigmoide. Chirurgie 98, 437. KILLEN D. A. (1964) Injury of the superior mesenteric vessels secondary to non-penetrating abdominal trauma. Am. Surg. 30, 306. KULOWSKI J. and ROST W. B. (1956) Intra-abdominal injury from safety belt in auto accident. Arch. Surg. 73, 970. MATHIESON A. J. M. (1962) Closed abdominal injury. Br. Ned. J. 2, 749.
Injury : the British Journal of Accident Surgery Vol. 7/No. 4
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