1217

Rupture of the Bowel After Blunt

Abdominal Trauma: Diagnosis with CT

Stuart E. Mirvis1 OBJECTIVE. The accuracy of CT in the detection of injuries of the solid viscera after
David R. Gens2 blunt trauma is well established, but the value of CT in diagnosing bowel rupture

Kathirkamanathan Shanmuganathan1 resulting from blunt trauma is controversial. This study was conducted to determine the
sensitivity of CT in diagnosing posttraumatic bowel rupture.
American Journal of Roentgenology 1992.159:1217-1221.

SUBJECTS AND METHODS. Dunng a 51-month period, 17 preoperative CT scans

were obtained in 16 patients who subsequently had bowel ruptures verified surgically.
Both preoperative (prospective) and retrospective CT findings were analyzed in these
patients. Retrospective interpretation was made by consensus of two radiologists.
RESULTS. Surgically confirmed bowel ruptures occurred in the duodenum (five), ileum
(four), jejunum (four), colon (four), and stomach (two). CT findings considered diagnostic
of bowel perforation were detected prospectively on 10 (59%) of 17 scans; these
included pneumoperitoneum without prior peritoneal lavage (six), mesenteric, intramural,
or retropentoneal free air (six), or direct visualization of discontinuity of the bowel wall
or extravasation of luminal contents (four). Prospective CT findings considered sugges-
tive of bowel rupture were present on five (29%) of the 17 scans; these included
intraperitoneal fluid of unknown source (three), thickened (>4-5 mm) bowel wall (two),
gross anterior pararenal fluid without a recognized source (one), and a mesenteric-
bowel wall hematoma (one). On two of 17 scans, findings were seen in retrospect only;
these included free intraperitoneal blood without a source (findings on a second CT
scan were diagnostic) and pneumopentoneum. CT findings diagnostic or suggestive of
bowel injury were detected prospectively on 15 (88%) of 17 scans and were noted in all
retrospectively.
CONCLUSION. CT is sensitive for the diagnosis of bowel rupture resulting from blunt
trauma, but careful inspection and technique are required to detect often subtle findings.

AJR 159:1217-1221, December 1992

The sensitivity of CT in the detection of bowel rupture remains to be established.

Numerous earlier studies [1 -6] found poor sensitivity of CT for detection of bowel
injuries; others [7, 8] have claimed high sensitivity of CT for diagnosing bowel
injuries and for distinguishing those bowel injuries that are likely to require surgical
intervention. The discrepancy in these observations may arise from the type of
Received April 6, 1992; accepted after revision study (prospective vs retrospective interpretation), the sophistication of the CT
May 22, 1992. equipment used, the expertise of the interpreters, the types of bowel or mesenteric
Presented at the third annual meeting of the injuries evaluated in the study (e.g., bowel rupture, serosal tear, mesenteric injury,
American Society of Emergency Radiology, San
ischemic injury, bowel wall contusion), the oral administration of contrast material
Antonio, TX, March 1992.
or the lack thereof, and the performance of diagnostic peritoneal lavage before CT.
I Department of Diagnostic Radiology, University
of Maryland Medical Center, 22 5. Greene St., In light of this controversy, we analyzed both prospective and retrospective
Baltimore, MD 21 201 . Address reprint requests to interpretation of CT scans of patients with surgically proved bowel rupture identified
S. E. Mirvis.
from our trauma registry [9].
2 Shock Trauma Center, University of Maryland
Medical Center, 22 5. Greene St., Baltimore, MD
21201. Subjects and Methods
0361 -803X/92/1 596-1217 During a 51 -month period, from July 1987 to October 1991 , 48 patients had surgically
© American Roentgen Ray Society
confirmed bowel rupture resulting from blunt abdominal trauma that required surgical resec-
 1218 MIRVIS ET AL. AJR:159, December 1992

Fig. 1.-Jejunal perforation in 17-

year-old involved in motorcycle acci-
dent.
A, CT scan shows intraperitoneal
fluid below diaphragm on both sides
and minimal pneumoperitoneum (ar-
row).
B, CT scan through mid abdomen
shows intraperitoneal free fluid and
markedly thickened loops of proximal
portion of small bowel (arrows). Jejunal
transection was confirmed at surgery.
(Reprinted with permission from
Mirvis and Shanmuganathan [10].)

tion. Patients with ischemic bowel, degloving bowel injuries (avulsion wall discontinuity in three (Fig. 5), with extraluminal extrava-
of the serosa), or isolated
mesenteric injuries were not included in sation of contrast material (Fig. 2) or feces (Fig. 4). Many
this study. Among these 48 patients, 1 6 (33%) had preoperative CT, additional supporting findings were observed in these 10
which was performed before diagnostic peritoneal lavage in all cases.
patients. These included bowel wall thickening in four (Fig. 1),
These 16 included 14 men and two women 16-50 years old (mean,
free intraperitoneal fluid in four (Figs. 1 and 3), and anterior
American Journal of Roentgenology 1992.159:1217-1221.

26 years). Mechanisms of injury included automobile accidents (1 1),

motorcycle accidents (two), and crushing injuries (three). pararenal or intramesenteric fluid in three (Figs. 2 and 5).
CT scans were obtained by using a Siemens DRH (July 1 987 to CT findings regarded as suggestive of bowel rupture were
March 1 990) with a routine 3-sec scan time or a Siemens Hi-Q (March noted in another five of the 1 7 scans on prospective interpre-
1 990 to October 1991) with a routine 2-sec scan time (Siemens tation, including diffuse thickening of the bowel wall in two
Medical Systems, Iselin, NJ). Most of the preoperative CT scans (14) (Fig. 6), gross anterior pararenal fluid without a known source
were obtained with the Hi-Q scanner later in the study because of a in two (Fig. 7), and transmural bowel wall hematoma in one
generalized increase in the use of CT for evaluation of abdominal (Fig. 8). Two findings were not made on prospective interpre-
trauma during this period and because of the proximity of the scanner tation but were found retrospectively. One patient had minimal
to the area where patients were admitted. All patients received oral
free pelvic fluid of low attenuation without a recognized
contrast material consisting of 5 g of Hypaque powder (Winthrop
source; a subsequent preoperative CT scan obtained 44 hr
Pharmaceuticals, New York, NY) or 1 0 ml of 37% Gastrografin
(Squibb Diagnostics, Princeton, NJ) in 10 oz (300 ml) of water 30-45
after the initial study, because of the patient’s increasing
mm before the scan and a second dose either orally or by nasogastric abdominal pain and fever, showed findings diagnostic of
tube when they arrived at the scanning suite. Contrast material was bowel injury, including pneumoperitoneum and free intraperi-
not administered rectally in these cases. When the DRH scanner was toneal fluid (Fig. 9). Initially missed CT findings in another
used, contrast material was given IV as a hand-injected bolus of 100 patient included pneumoperitoneum and perigastric omental
ml of 60% Renografin (Squibb Diagnostics) before scanning; this was gas. This patient had several obvious major injuries of the
followed by a drip infusion of 30% contrast material (average, 200 solid viscera that necessitated urgent laparotomy. Overall,
ml). When the Hi-Q scanner was used, contrast material was given
diagnostic or suggestive findings of bowel rupture were ob-
IV as a power-injected bolus of 100 ml of 60% Hypaque (at 2 mI/sec)
served prospectively in 1 5 (88%) of 17 CT studies and in all
before scanning; this was followed by an infusion of an additional
cases retrospectively. None of the patients who were exam-
50-1 00 ml of 60% contrast material at a rate of 0.7-1 .0 mI/sec.
med by CT for blunt abdominal trauma during the study (2237
Preoperative interpretations of the CT scans were compared with
surgical findings. In addition, CT scans were reviewed by two of the scans obtained) and who had CT findings that were diagnostic
authors in all surgically proved cases of ruptured bowel, and CT of bowel rupture were successfully managed without surgery,
findings were compared with the initial interpretations and surgical and in all these cases bowel rupture was verified surgically.
findings.

Discussion
Results
Several studies on the accuracy of CT for detecting bowel
Nineteen surgically confirmed bowel ruptures were de- rupture in patients undergoing exploratory laparotomy have
tected: five to the duodenum, four to the jejunum, four to the reported poor sensitivity. Cook et al. [6] evaluated CT results
ileum, four to the colon, and two to the stomach. Preoperative in 83 patients with upper abdominal trauma. In three patients
CT findings considered diagnostic of bowel rupture were with surgically proved small-bowel perforation, the injury was
noted in 1 0 (63%) of these 1 6 patients. These included missed on CT, although in one who had duodenal injury, CT
pneumoperitoneum without an intrathoracic source or pre- findings indicating perforation were seen retrospectively. Two
vious peritoneal lavage in six (Fig. 1) [1 0]; extraperitoneal gas of these 83 patients, in whom CT findings suggested duo-
in the mesentery (Fig. 2), bowel wall (Fig. 3) [1 1 ], or retro- denal rupture, had no injury found during surgery (false-
peritoneum (Fig. 4) in six; and direct visualization of bowel positive). In a subsequent report, Hofer and Cohen [12]
 AJA:159, December 1992 CT OF BOWEL RUPTURE 1219

Fig. 2.-Duodenal perforation in 28-year-old woman after motor vehicle accident.

A, CT scan through mid abdomen shows extravasation of contrast material posterior to third portion of duodenum (arrows).
B, A more caudal CT scan shows one large and several small irregular gas collections in mesentery, fluid dissecting into mesentery, and fluid-filled
distended small bowel.
C, CT scan through upper pelvis shows still further caudal dissection of mesenteric gas (arrow).
American Journal of Roentgenology 1992.159:1217-1221.

Fig. 3.-Duodenal rupture in a 16-year-old with blunt Fig. 4.-Cecal perforation in a 40-year-old who sustained crushing injury.
trauma. CT scan shows thickening of duodenal wall and A, CT scan through upper abdomen shows retroperitoneal gas (arrowheads) and pneu-
a dot of gas in wall (arrow). Gas extends into wall of moperitoneum (arrows).
gallbladder. Gross intraperitoneal free fluid and pneumo- B, CT scan through lower abdomen shows disruption of cecum, with extrusion of feces
peritoneum are seen. (Reprinted with permission from into right pericolic gutter (arrows). Cecal perforation was confirmed surgically.
Mirvis and Dunham [11]. © 1992, the Williams & Wilkins (Reprinted with permission from Mirvis and Dunham [11]. © 1992, the Williams & Wilkins
Co., Baltimore.) Co., Baltimore.)

Fig 5.-Duodenal disruption in 18-

year-old man involved in motor vehicle
collision.
A, CT scan through mid abdomen
shows perforation of posterior duo-
denal wall (arrow) and obvious fluid in
anterior pararenal space.
B, More caudal CT scan shows
marked extravasation of fluid in ante-
nor pararenal space and abrupt inter-
ruption in continuity of third portion of
duodenum (arrow). Perforations of sec-
ond and third portions of duodenum
were surgically confirmed.
 1220 MIRVIS ET AL. AJR:159, December 1992

Fig. 6.-Possible jejunal rupture in a 17-year- Fig. 7.-Possible duodenal rupture in 32-year-old woman involved in motor vehicle collision.
old after crushing injury. CT scan shows marked A, CT scan shows marked retroperitoneal (anterior pararenal) fluid and narrowing of third portion
thickening of proximal jejunum (arrowheads). of duodenum (arrows). Some intraperitoneal fluid is present.
Some free intraperitoneal fluid (not shown) also B, More caudal CT scan suggests abrupt interruption of third portion of duodenum (arrow). At
was observed. Proximal jejunal rupture was found surgery, ruptures of second and third portions of duodenum were found.
at surgery. (Reprinted with permission from Mirvis (Reprinted with permission from Mirvis and Dunham [11]. © 1992, the Williams & Wilkins Co.,
and Dunham [1 1]. © 1992, the Williams & Wilkins Baltimore.)
Co., Baltimore.)
American Journal of Roentgenology 1992.159:1217-1221.

Fig. 8.-Possible bowel rupture in a 20-year-old after Fig. 9.-Delayed diagnosis of bowel perforation in 50-year-old injured in a motorcycle
motor vehicle collision. CT scan shows large heteroge- accident.
neous mass in right lower quadrant of abdomen. Diag- A, Initially findings on CT scan were interpreted as normal. On retrospective review, a small
nostic considerations included bowel or mesenteric he- amount of free intraperitoneal fluid (arrow) was recognized in pelvis.
matoma. At surgery, a large cecal transmural hematoma B, CT scan obtained 2 days after A, because patient had abdominal pain and fever, shows
and perforation of ascending colon were found, which marked pneumoperitoneum and free intraperitoneal fluid. At surgery, a ruptured jejunum was
required segmental resection. (Reprinted with permis- diagnosed.
sion from Mirvis and Dunham [11]. © 1992, the Williams (Reprinted with permission from Mirvis and Shanmuganathan [10].)
& Wilkins Co., Baltimore.)

described CT findings in two patients with duodenal perfora- firmed at surgery. These authors compared CT findings indic-
tion, including free intraperitoneal or extraperitoneal gas, ex- ative of bowel injury between 32 patients who underwent
travasation of opacified oral contrast material into the right celiotomy and 1 9 who were managed by observation. Al-
pararenal space, focal thickening of the duodenum in its though some overlap of CT findings occurred, patients
midportion that prevented passage of contrast material, and undergoing laparotomy had a higher prevalence of pneumo-
high-attenuation intramural duodenal hematoma. peritoneum (32%), free intraperitoneal fluid (96%), and
Two retrospective series on the accuracy of CT in detecting associated injuries (43%) than did patients managed nonop-
bowel injuries have been reported. Both series were derived eratively (0%, 21 %, and 5%, respectively). Rizzo et al. [8]
from the experience at the San Francisco General Hospital emphasized the value of CT in detecting signs of bowel and
and include data from overlapping periods [7, 8]. The larger mesenteric injury and in distinguishing injuries requiring sur-
series by Rizzo et al. [8] includes a retrospective review of gery from those that do not. Unfortunately, that study was a
51 patients in whom CT findings suggested bowel or mes- retrospective review, and the influence of the CT findings of
enteric injuries and compares CT findings with surgical out- potential bowel injury on the decision to proceed to laparot-
come. In this series, CT showed evidence of significant bowel omy cannot be ascertained.
injury in 26 (93%) of 28 patients whose injuries were con- Although our study included fewer patients, it was a pro-
 AJR:159, December 1992 CT OF BOWEL RUPTURE 1221

spective evaluation of CT for the detection of bowel rupture. trast, and appropriate review of images optimized for detec-
We compared CT findings with surgical results specifically In tion of minimal pneumoperitoneum will improve sensitivity of
patients with bowel rupture and did not assess the accuracy CT for diagnosis of bowel rupture.
of CT for diagnosing bowel ischemia related to blunt trauma,
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