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Massive rectal bleeding distant from a blunt car trauma
Gastroentérologie Clinique et Biologique (2010) 34, 499—501
CASE REPORT
Massive rectal bleeding distant from a blunt car trauma Saignement massif à distance d’un traumatisme contusif, suite à un accident de voiture E. Gruden a, E. Ragot a, R. Arienzo a, A. Revaux a, M. Magri a, M. Grossin b, C. Leroy c, S. Msika a, R. Kianmanesh a,∗ a
Departments of General and Digestive Surgery, Louis-Mourier University-Hospital, AP—HP, Paris Diderot (Paris-7) University, 178, rue des Renouillers, 92701 Colombes cedex, France b Department of Pathology, Louis-Mourier University-Hospital, AP—HP, Paris Diderot (Paris-7) University, 92701 Colombes cedex, France c Department of Emergency, Louis-Mourier University-Hospital, AP—HP, Paris Diderot (Paris-7) University, 92701 Colombes cedex, France Available online 16 July 2010
Summary Mesenteric trauma is one of the possible injuries caused by the use of seat belts in case of motor vehicle crash. We report here a rare case of rectal bleeding by rupture of a mesosigmoid haematoma. An emergent laparotomy revealed a mesosigmoid haematoma with a centimetric rectal perforation. The wearing of safety belts added some specific blunt abdominal trauma, which directly depends on lap-and-sash belts. Mesenteric injuries are found out up to 5% of blunt abdominal traumas. ‘‘Seat belt mark’’ leads the surgical team to strongly suspect an intra-abdominal trauma. When ‘‘seat belt mark’’ sign is found, in patients with mild to severe blunt car injuries, CT-scan has to be realised to eliminate intra-abdominal complications, including mesenteric and mesosigmoid ones. In case of proved mesenteric haematoma associated to intestinal bleeding, a surgical treatment must be considered as first choice. Conservative approach remains possible in stable patients but surgical exploration remains necessary in unstable patients with active bleeding. © 2010 Elsevier Masson SAS. All rights reserved. Résumé Le traumatisme du mésentère est un des dommages causés par l’utilisation de la ceinture de sécurité en cas d’accident de véhicule. Nous reportons ici un rare cas de rectorragie dû à la rupture d’un hématome du mésosigmoïde. Une laparotomie en urgence a révélé un hématome du mésosigmoïde avec perforation rectale centimétrique. L’utilisation de la ceinture
∗
Corresponding author. E-mail address: [email protected] (R. Kianmanesh).
0399-8320/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.gcb.2010.05.008
500
E. Gruden et al.
de sécurité a rajouté des caractéristiques spécifiques aux traumatismes abdominaux dépendant directement du système des ceintures à trois points. Les plaies du mésentère sont constatées jusqu’à 5 % des traumatismes contusifs abdominaux. Le « signe de la ceinture de sécurité » conduit l’équipe chirurgicale à suspecter fortement un traumatisme intra-abdominal. Lors que le « signe de la ceinture de sécurité » est retrouvé chez les patients qui présentent des contusions suite à un accident de voiture, une TDM devrait être réalisée afin d’exclure la présence de complications intra-abdominales, y compris celles du mésosigmoïde. En cas d’hématome du mésentère prouvé, avec rectorragie, le traitement chirurgical devrait être le traitement de choix. Un traitement conservatif est envisageable chez les patients stables mais l’exploration chirurgicale demeure nécessaire chez les patients instables avec saignement actif. © 2010 Elsevier Masson SAS. Tous droits réservés.
Introduction Mesenteric trauma is one of the possible injuries caused by the use of seat belts in case of motor vehicle crash [1]. In addition, this is often associated to delayed time in diagnosis and therapy approach. Reports about this trauma are infrequent and usually associated to other intra-abdominal injuries. We report here a rare case of rectal bleeding by probable rupture of a mesosigmoid haematoma in the upper part of rectum 10 days after a serious blunt car injury.
Observation A 54-year-old man admitted at hospital 10 days after a vehicle accident (driver) for illness sensation followed by rectal bleeding. He has been treated for two fractures one at a whistle and the other at a leg immediately after the accident and discharged with 4500 UI per day of tinzaparin sodium. Clinically, his blood pressure was 80/40 mmHg, pulse 110 per minute. Abdominal inspection noticed the typical aspect of the ‘‘seat belt mark’’ represented by ecchymosis and haematomas corresponding to safety belt contact points. The abdomen was tender to palpation. Haemoglobin was at 9,4 g/dL. An injected computed tomography showed a haematoma (2,5 × 3,5 × 4,5 cm) in mesosigmoid with an iso-
lated air image inside the haematoma near the upper part of the rectum suggesting a possible colorectal communication between the haematoma and the rectum (Figs. 1a and b). There was no evidence of active bleeding, considering the limits of the CT-scan in the evaluation of such a parameter, when the flow is not important. There was no pneumoperitoneum. An emergent laparotomy revealed a mesosigmoid haematoma with a mild amount of free bloody liquid in closed to a wound of mesosigmoid peritoneal layers. Following this rupture permitted to find a centimetric rectal perforation localised on the posterior wall. Surgical resection was performed with colon-rectal sideto-end anastomosis. The specimen’s anatomic-pathological evaluation indicated a colic acute perforation with mesenteric haematoma and peritoneal reaction, according to a traumatic origin (Fig. 2). The post-operative course was uneventful and patient was discharged 14 days after admission.
Discussion ‘‘Seat belt syndrome’’ is an entity, created by introduction of restraint safety systems on motor vehicles [1]. The wearing of safety belts added some specific blunt abdominal trauma, which directly depends on lap-and-sash belts. Mesenteric injuries are found out up to 5% of blunt abdom-
Figure 1 a: CT-scan showing a small vascular tonality image inside mesosigmoid. b: Coronal view shows inside the mesosigmoid small bubbles demonstrating communication with digestive tube.
Delayed post-trauma rectal bleeding
501 This shows the importance of CT-scan in presence of ‘‘seat belt mark’’ sign in patients with mild to severe blunt car injuries to eliminate intra-abdominal including mesenteric and mesosigmoid complications. Usually conservative approach remains possible in stable patients; however, surgical exploration is mandatory in unstable patients with active bleeding.
Conflict of interest statement No potential conflict of interest relevant to this article was reported.
References Figure 2 Pathological gross view of the resected (R) specimen showing the posterior communication between the mesosigmoid and the haematoma (arrow).
inal traumas [2], regarding of the small bowel or the gut or both. Colon injuries are rarer than small bowel’s ones [4]. In the present report, the ‘‘seat belt mark’’ sign, which lead the surgical team to strongly suspect an intra-abdominal trauma. This aspect of clinical presentation appears as an important element in the decision flow-chart. The presence of such a mark has been associated to an elevated incidence of significant organ injuries [3]. There are several studies describing the importance of early diagnosis. In this context, it is necessary to emphasize how a long delay is associated with higher percentages of morbidity and hospital stay even though authors agree about no increasing of mortality rates [4,5]. Computed tomography has been indicated as the most accurate imaging tool in the diagnosis of intra-abdominal injuries, particularly regarding of mesenteric blunt trauma [6,7]. The therapeutic approach depends on quantity and quality of lesions. In case of proved mesenteric haematoma associated to intestinal bleeding, a surgical treatment must be considered as first choice therapy even if in some selected cases arterial embolization could successfully be used [8].
[1] Vellar ID, Vellar DJ, Mullany CJ. Rupture of the bowel due to road trauma. The emergence of the ‘‘seat belt syndrome’’. Med J Aust 1976;1:694—6. [2] Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multi-detector CT. Radiographics 2006;26:1119—31. [3] Velmahos GC, Tatevossian R, Demetriades D. The ‘‘seat belt mark’’ sign: a call for increased vigilance among physicians treating victims of motor vehicle accident. Am Surg 1999;65:181—5. [4] Xeropotamos NS, Nousias VE, Ioannou HV, Kappas AM. Mesenteric injury after blunt abdominal trauma. Eur J Surg 2001;167:106—9. [5] Shebrain S, Zelada J, Lipsky AM, Putnam B. Mesenteric injuries after blunt abdominal trauma: delay in diagnosis and increased morbidity. Am Surg 2006;72:955—6. [6] Brown MA, Casola G, Sirlin CB, Patel NY, Hoyt DB. Blunt abdominal trauma: screening US in 2693 patients. Radiology 2001;218:352—8. [7] Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004;56:314—22. [8] Kakizawa H, Toyota N, Hieda M, Ishida M, Takeda T, Matsuura K, et al. Traumatic mesenteric bleeding managed solely with transcatheter embolization. Radiat Med 2007;25: 295—8.
CASE REPORT
Massive rectal bleeding distant from a blunt car trauma Saignement massif à distance d’un traumatisme contusif, suite à un accident de voiture E. Gruden a, E. Ragot a, R. Arienzo a, A. Revaux a, M. Magri a, M. Grossin b, C. Leroy c, S. Msika a, R. Kianmanesh a,∗ a
Departments of General and Digestive Surgery, Louis-Mourier University-Hospital, AP—HP, Paris Diderot (Paris-7) University, 178, rue des Renouillers, 92701 Colombes cedex, France b Department of Pathology, Louis-Mourier University-Hospital, AP—HP, Paris Diderot (Paris-7) University, 92701 Colombes cedex, France c Department of Emergency, Louis-Mourier University-Hospital, AP—HP, Paris Diderot (Paris-7) University, 92701 Colombes cedex, France Available online 16 July 2010
Summary Mesenteric trauma is one of the possible injuries caused by the use of seat belts in case of motor vehicle crash. We report here a rare case of rectal bleeding by rupture of a mesosigmoid haematoma. An emergent laparotomy revealed a mesosigmoid haematoma with a centimetric rectal perforation. The wearing of safety belts added some specific blunt abdominal trauma, which directly depends on lap-and-sash belts. Mesenteric injuries are found out up to 5% of blunt abdominal traumas. ‘‘Seat belt mark’’ leads the surgical team to strongly suspect an intra-abdominal trauma. When ‘‘seat belt mark’’ sign is found, in patients with mild to severe blunt car injuries, CT-scan has to be realised to eliminate intra-abdominal complications, including mesenteric and mesosigmoid ones. In case of proved mesenteric haematoma associated to intestinal bleeding, a surgical treatment must be considered as first choice. Conservative approach remains possible in stable patients but surgical exploration remains necessary in unstable patients with active bleeding. © 2010 Elsevier Masson SAS. All rights reserved. Résumé Le traumatisme du mésentère est un des dommages causés par l’utilisation de la ceinture de sécurité en cas d’accident de véhicule. Nous reportons ici un rare cas de rectorragie dû à la rupture d’un hématome du mésosigmoïde. Une laparotomie en urgence a révélé un hématome du mésosigmoïde avec perforation rectale centimétrique. L’utilisation de la ceinture
∗
Corresponding author. E-mail address: [email protected] (R. Kianmanesh).
0399-8320/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.gcb.2010.05.008
500
E. Gruden et al.
de sécurité a rajouté des caractéristiques spécifiques aux traumatismes abdominaux dépendant directement du système des ceintures à trois points. Les plaies du mésentère sont constatées jusqu’à 5 % des traumatismes contusifs abdominaux. Le « signe de la ceinture de sécurité » conduit l’équipe chirurgicale à suspecter fortement un traumatisme intra-abdominal. Lors que le « signe de la ceinture de sécurité » est retrouvé chez les patients qui présentent des contusions suite à un accident de voiture, une TDM devrait être réalisée afin d’exclure la présence de complications intra-abdominales, y compris celles du mésosigmoïde. En cas d’hématome du mésentère prouvé, avec rectorragie, le traitement chirurgical devrait être le traitement de choix. Un traitement conservatif est envisageable chez les patients stables mais l’exploration chirurgicale demeure nécessaire chez les patients instables avec saignement actif. © 2010 Elsevier Masson SAS. Tous droits réservés.
Introduction Mesenteric trauma is one of the possible injuries caused by the use of seat belts in case of motor vehicle crash [1]. In addition, this is often associated to delayed time in diagnosis and therapy approach. Reports about this trauma are infrequent and usually associated to other intra-abdominal injuries. We report here a rare case of rectal bleeding by probable rupture of a mesosigmoid haematoma in the upper part of rectum 10 days after a serious blunt car injury.
Observation A 54-year-old man admitted at hospital 10 days after a vehicle accident (driver) for illness sensation followed by rectal bleeding. He has been treated for two fractures one at a whistle and the other at a leg immediately after the accident and discharged with 4500 UI per day of tinzaparin sodium. Clinically, his blood pressure was 80/40 mmHg, pulse 110 per minute. Abdominal inspection noticed the typical aspect of the ‘‘seat belt mark’’ represented by ecchymosis and haematomas corresponding to safety belt contact points. The abdomen was tender to palpation. Haemoglobin was at 9,4 g/dL. An injected computed tomography showed a haematoma (2,5 × 3,5 × 4,5 cm) in mesosigmoid with an iso-
lated air image inside the haematoma near the upper part of the rectum suggesting a possible colorectal communication between the haematoma and the rectum (Figs. 1a and b). There was no evidence of active bleeding, considering the limits of the CT-scan in the evaluation of such a parameter, when the flow is not important. There was no pneumoperitoneum. An emergent laparotomy revealed a mesosigmoid haematoma with a mild amount of free bloody liquid in closed to a wound of mesosigmoid peritoneal layers. Following this rupture permitted to find a centimetric rectal perforation localised on the posterior wall. Surgical resection was performed with colon-rectal sideto-end anastomosis. The specimen’s anatomic-pathological evaluation indicated a colic acute perforation with mesenteric haematoma and peritoneal reaction, according to a traumatic origin (Fig. 2). The post-operative course was uneventful and patient was discharged 14 days after admission.
Discussion ‘‘Seat belt syndrome’’ is an entity, created by introduction of restraint safety systems on motor vehicles [1]. The wearing of safety belts added some specific blunt abdominal trauma, which directly depends on lap-and-sash belts. Mesenteric injuries are found out up to 5% of blunt abdom-
Figure 1 a: CT-scan showing a small vascular tonality image inside mesosigmoid. b: Coronal view shows inside the mesosigmoid small bubbles demonstrating communication with digestive tube.
Delayed post-trauma rectal bleeding
501 This shows the importance of CT-scan in presence of ‘‘seat belt mark’’ sign in patients with mild to severe blunt car injuries to eliminate intra-abdominal including mesenteric and mesosigmoid complications. Usually conservative approach remains possible in stable patients; however, surgical exploration is mandatory in unstable patients with active bleeding.
Conflict of interest statement No potential conflict of interest relevant to this article was reported.
References Figure 2 Pathological gross view of the resected (R) specimen showing the posterior communication between the mesosigmoid and the haematoma (arrow).
inal traumas [2], regarding of the small bowel or the gut or both. Colon injuries are rarer than small bowel’s ones [4]. In the present report, the ‘‘seat belt mark’’ sign, which lead the surgical team to strongly suspect an intra-abdominal trauma. This aspect of clinical presentation appears as an important element in the decision flow-chart. The presence of such a mark has been associated to an elevated incidence of significant organ injuries [3]. There are several studies describing the importance of early diagnosis. In this context, it is necessary to emphasize how a long delay is associated with higher percentages of morbidity and hospital stay even though authors agree about no increasing of mortality rates [4,5]. Computed tomography has been indicated as the most accurate imaging tool in the diagnosis of intra-abdominal injuries, particularly regarding of mesenteric blunt trauma [6,7]. The therapeutic approach depends on quantity and quality of lesions. In case of proved mesenteric haematoma associated to intestinal bleeding, a surgical treatment must be considered as first choice therapy even if in some selected cases arterial embolization could successfully be used [8].
[1] Vellar ID, Vellar DJ, Mullany CJ. Rupture of the bowel due to road trauma. The emergence of the ‘‘seat belt syndrome’’. Med J Aust 1976;1:694—6. [2] Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multi-detector CT. Radiographics 2006;26:1119—31. [3] Velmahos GC, Tatevossian R, Demetriades D. The ‘‘seat belt mark’’ sign: a call for increased vigilance among physicians treating victims of motor vehicle accident. Am Surg 1999;65:181—5. [4] Xeropotamos NS, Nousias VE, Ioannou HV, Kappas AM. Mesenteric injury after blunt abdominal trauma. Eur J Surg 2001;167:106—9. [5] Shebrain S, Zelada J, Lipsky AM, Putnam B. Mesenteric injuries after blunt abdominal trauma: delay in diagnosis and increased morbidity. Am Surg 2006;72:955—6. [6] Brown MA, Casola G, Sirlin CB, Patel NY, Hoyt DB. Blunt abdominal trauma: screening US in 2693 patients. Radiology 2001;218:352—8. [7] Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004;56:314—22. [8] Kakizawa H, Toyota N, Hieda M, Ishida M, Takeda T, Matsuura K, et al. Traumatic mesenteric bleeding managed solely with transcatheter embolization. Radiat Med 2007;25: 295—8.