Small Bowel (Jejunum/Ileum) Trauma

Small Bowel (Jejunum/Ileum) Trauma

David Ray Velez, MD

Table of Contents

Background
Presentation and Diagnosis
Treatment
Mesenteric Injury

Duodenal Trauma is Generally Considered Separate from Other Small Bowel Trauma – *See Duodenal Trauma

Background

Etiology

  • The Most Commonly Injured Organ (50%) After Penetrating Abdominal Trauma
  • Third Most Common Injury (5-10%) After Blunt Abdominal Trauma
    • Behind Spleen and Liver
    • Blunt Injuries are Most Often Near Sites of Attachment (Ligament of Treitz, Ileocecal Valve, or Adhesions)

Mechanism of Injury

  • Penetrating Mechanisms:
    • Direct Injury – Tearing & Crushing Force Through Tissue Along the Trajectory of the Projectile & its Fragments
      • Gunshot Wounds Have an Additional Dissipation of Kinetic Energy That Causes Further Damage
    • Cavitation – As a High Energy Projectile Moves Through Tissue Energy Causes a Radial Stretching, Forming a Temporary Cavity with Additional Tissue Damage
      • Higher Energy Projectiles Create Larger Cavities & Cause More Damage
    • Shock Wave – The Projectile Creates Rapid Changes in Pressure & Temperature that Propagate Through Tissue Causing Additional Injury
  • Blunt Mechanisms:
    • Crushing Force – Direct Compression Causing Injury
    • Shearing Force – Tearing from Acceleration/Deceleration Around Fixed Attachments
    • Bursting Force – Force Causing Acutely Increased Intraluminal Pressure within Hollow Organs Leading to Rupture

Small Bowel Perforation 1

Presentation and Diagnosis

Presentation

  • Mostly Nonspecific
  • Abdominal Pain
  • Nausea and Vomiting

May Be Diagnosed on CT or Intraoperatively

Small Bowel is the Most Commonly Missed Abdominopelvic Injury on CT in Trauma

AAST Small Bowel Injury Grade

Treatment

Delay to Surgery with Perforation is Associated with Increased Morbidity and Mortality

Free Fluid on CT without Solid Organ Injury Should Raise Immediate Concern for Hollow Viscus Injury – Does Not Absolutely Mandate Surgical Exploration but Should At Least Be Monitored Closely with Serial Examinations if Not Operating

Intramural Hematoma: Generally Managed Conservatively (Explore if Large or Expanding)

Definition of “Destructive” Bowel Injury

  • Laceration > 50% Circumference or Transection
  • Devascularized or “Bucket Handle” Injury

Non-Destructive Injury (Grade I-II): Primary Repair

  • Close Transversely to Avoid Stricture if Able
  • Close in One or Two-Layers – No Difference in Complication Rates
  • May Convert Two Perforations Closely Opposed into a Single Defect
  • Consider Resection if There are Multiple Small Perforations in a Short Segment

Destructive Injury (Grade III-V): Small Bowel Resection

  • Anastomosis Can Be Handsewn or Stapled – No Difference in Complication Rates
  • Close the Mesenteric Defect to Prevent Internal Hernia

Leave as Much Bowel as Possible with the Fewest Number of Repairs or Anastomoses to Prevent Short Gut Syndrome – *See Intestinal Failure – The O.R.

Mesenteric Injury

Mesenteric Hematoma

  • Small and Nonexpanding: Conservative Management
  • Large or Expanding: Explore and Evacuate the Hematoma

Mesenteric Tear

  • Close All Defects to Prevent Internal Hernia
  • Tear Alone Does Not Mandate Bowel Resection Unless Devascularized

“Bucket Handle” Injury 

  • Definition: Mesenteric Separation from the Bowel Causing Devascularization
  • Most Common After Motor Vehicle Crash (MVC) – Requires Significant Force
  • Most Common Site: Terminal Ileum
    • Tend to Occur Near Areas of Fixation (Cecum/Ligament of Treitz)
  • Treatment: Resection of Devitalized Bowel

Mesenteric Hematoma 2

Mesenteric Tear 3

Multiple Bucket Handle Injuries 4

References

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