Mesenteric Hematoma Research Articles

特発性小腸腸間膜血腫の１切除例

特発性小腸腸間膜血腫の１切除例

Mesenteric haematoma or tear is the criminal

We read with interest the report by Lalwani et al. from New Delhi, India reporting 8 cases of delayed/late presentation of small bowel (SB) stricture following blunt abdominal trauma (BAT). Eight cases being reported from a single centre is an indication that this pathological phenomenon is more common than it has previously been described. Lalwani et al. have not mentioned the exact number of cases of BAT that were reviewed between 1996 and 2008 at their centre, which if known would help in estimating the incidence of delayed mesenteric stricture following BAT. We report here a case of a young man who had a delayed presentation of SB obstruction secondary to a stricture 16 days following a motorcycle crash. In our case, the initial computed tomography (CT) scan showed that the patient had a mesenteric haematoma, which was managed conservatively. The repeat enhanced-CT scan 16 days posttrauma—when the patient presented with vomiting and increased abdominal pain—showed a stenotic loop of distal ileum adjacent to an expanded mesenteric mass. Pathological evaluation following exploratory laparotomy and resection of the loop revealed a loop of stenotic SB with oedematous mesentery, mucosal atrophy, ulcerations and serosal fibrous adhesions which indicate ischaemic changes. We have found and referenced 12 other reports (mainly case reports) of delayed SB obstruction after BAT from the medical literature. Since then we have also reported a different case of a young man who had a delayed presentation (5 weeks) of SB perforation following a BAT (motorcycle accident). It is of note to mention that this patient was also found to have a mesenteric haematoma on initial abdominal CT scan which was managed conservatively. An exploratory laparotomy at the time of delayed presentation (peritonitis) 5 weeks after the initial trauma showed a perforated thickened loop of the ileum forming a phlegmon in the lower abdomen. In the English medical literature, we found only 8 other reports of delayed post-traumatic presentation of ileal/jejunal perforation following BAT. The fact that there are very few reported cases in the literature for both the complications (SB stricture and/or perforation following BAT), is an evidence that these pathologies are not well represented and reported in the literature. A shared feature in the majority of the reported cases in the literature is the presence of minor tears and contusions of the mesentery, and/or mesenteric haematoma. Direct mechanical intestinal injury is unlikely to be the cause in situations where delayed presentation of SB stricture or perforation lags a few weeks or even months post-trauma. It is also unrealistic that an initial post-traumatic SB perforation goes undiagnosed for such a long period of time. In the above-mentioned case series of 8 patients with delayed post-traumatic SB stricture reported by Lalwani et al., the authors have reported a history of mesenteric tear repair in one of the patients, diagnostic laparoscopy in the second patient, and laparotomy with lysis of adhesion in the third patient (highly likely to cause mesenteric tears). There was also a reported case (fourth patient) with a thrombus involving the portal vein, extending into the superior mesenteric vein which could affect the blood circulation in the SB mesentery. Although the immediate post-traumatic abdominal CT scans of the patients have not been reported by the authors, it would be interesting to know whether there has been any evidence to suggest the presence of mesenteric injuries or SB wall haematoma both of which could affect the blood circulation of a part of the bowel in the other four cases.

Dilemma of Blunt Bowel Injury: What are the Factors Affecting Early Diagnosis and Outcomes

Blunt bowel and mesenteric injury (BBMI) is frequently a difficult diagnosis at initial presentation. We aimed to study the predictors for early diagnosis and outcomes in patients with BBMI. Data were collected retrospectively from the database registry between January 2008 and December 2011 in the only Level I trauma unit in Qatar. Patients with BBMI were divided into Group A (surgically treated within 8 hours) and Group B (treated after 8 hours). Data were analyzed and χ2, Student's t test, and multivariate regression analysis were performed appropriately. Among 984 patients admitted with blunt abdominal trauma (BAT), 11 per cent had BBMI with mean age of 35 ± 9.5 years. Polytrauma and isolated bowel injury were identified in 53 and 42 per cent, respectively. Mean Injury Severity Score (ISS) was higher in Group A in comparison to Group B (18 ± 11 vs. 13 ± 8; P = 0.02). Presence of pain and seatbelt sign (P = 0.02) were evident in Group B. Hypotension (P = 0.004) and hypothermia (P = 0.01) were prominent in Group A. The rate of positive Focused Assessment Sonography for Trauma was greater in Group A (P = 0.001). Among operative findings, bowel perforation was more frequent in Group B (P = 0.04), whereas mesenteric full-thickness hematoma was significantly higher in Group A. Pelvic fracture was more frequent finding in Group A (P = 0.005). The overall mortality rate was 15.6 per cent. In patients with BAT, the presence of abdominal pain, hypotension, ISS greater than 16, hypothermia, pelvic fracture, and mesenteric hematoma might help in early diagnosis of BBMI. Moreover, base deficit and mean ISS were independent predictors of mortality. Delayed operative interventions greater than 8 hours increased morbidity rate but had no significant impact on mortality.

Mesenteric haematoma or tear is the criminal

Mesenteric haematoma or tear is the criminal

Detection of significant bowel and mesenteric injuries in blunt abdominal trauma with 64-slice computed tomography

Approximately 5% of blunt abdominal trauma patients experience blunt bowel and mesenteric injuries (BBMIs). The diagnosis may be elusive as computed tomography (CT) can occasionally miss these injuries. Recent advancements in CT technology, however, may improve detection rates. This study will assess the false-negative rate of BBMI using a 64-slice computed tomographic scanner in adults with blunt abdominal trauma. All blunt abdominal trauma patients with laparotomy confirmed BBMI were retrospectively identified within a 5-year period at a Level I trauma center. Only patients who underwent preoperative abdominal CT were included. CT reports were examined specifically for findings suggestive of BBMI and compared with operative findings. A completely normal computed tomographic scan result as interpreted by a staff radiologist but operative findings of BBMI was considered a false negative. One hundred ninety five cases of laparotomy-proven BBMI were identified from the trauma registry, of which 68 patients met study inclusion criteria. All study patients had free fluid present on CT. As a result, there were no false-negative computed tomographic scan results for BBMI. Four patients had isolated small amounts of free fluid without any additional suggestive CT findings of BBMI or solid-organ injury. Mesenteric or bowel hematomas and bowel wall thickening were present in 57% and 50% of cases, respectively. The false-negative rates of BBMI may be reduced with a 64-slice computed tomographic scan. In this study, all patients had free fluid identified on CT. Consequently, even minimal free fluid remains relevant in patients with blunt abdominal injury. Diagnostic test, level III.

Delayed small bowel perforation following blunt abdominal trauma: A case report and review of the literature

We report a case of delayed presentation of a small bowel perforation following blunt abdominal trauma (BAT). An initial computed tomography (CT) scan revealed that the patient (a 32-year-old man) had a mesenteric hematoma, which was managed conservatively. Four weeks later, he returned to the hospital complaining of abdominal pain. A CT scan of the abdomen showed a thickened loop of the small bowel adjacent to the mesenteric hematoma at the level of the ileum. He was discharged home, but re-presented with acute abdomen 6 weeks post-trauma. An exploratory laparotomy was performed, which showed a perforated thickened loop of the ileum forming a phlegmon in the lower abdomen. In the English medical literature, only eight other reports of delayed post-traumatic presentation of ileal/jejunal perforation following BAT have been reported. We propose that post-traumatic intestinal perforation be considered in the differential diagnosis even in patients who experience a delayed small bowel perforation following BAT.

Intestinal Stenosis From Mesenteric Injury After Blunt Abdominal Trauma in Children: Case Reports

The incidence of mesenteric injury after blunt abdominal trauma (BAT) has increased in recent years; however, relatively little attention has been paid to instances of its sequelae, especially in childhood. We present three children who had post-traumatic intestinal stenosis (PIS). A history of BAT was obtained in all. They had abdominal pain, bilious vomiting and peritoneal signs. The time intervals, the duration from the initial trauma to the onset of symptoms, ranged from 23 to 62 days. Stenotic segments were parallel to the location of the previously recognized mesenteric hematoma (MH), and resection with primary anastomosis was performed. Pathological examinations of specimens confirmed mucosal and mural ischemia and full-thickness fibrosis of the intestinal wall. In our opinion, large MH may pose an increasing risk of narrowing in the adjacent intestine at different time points. Therefore, if there is a large MH at laparotomy after BAT, it should be evacuated and the bleeding halted. For the differential diagnosis, typical BAT should be investigated carefully in cases presenting with intermittent colic abdominal pain and/or partial intestinal obstruction findings.

Spontaneous mesenteric hemorrhage

Spontaneous intra-abdominal hemorrhage or abdominal apoplexy is an acute abdominal emergency which can exhibit a wide spectrum of clinical presentation. With the expanding avenues for anticoagulation therapy, this condition is becoming commoner. The association of this condition with antiplatelet therapy is less well established. We present a case of spontaneous mesenteric hematomas causing intestinal obstruction in a patient on antiplatelet therapy for ischemic heart disease. A review of etiology, clinical presentation and protocol of management is also presented. A high index of suspicion on the part of the clinician is essential to ensure a favorable outcome in this condition.

A Case of Anticoagulant-Drug Induced Intramural and Mesenteric Hematoma of the Small intestine

A Case of Anticoagulant-Drug Induced Intramural and Mesenteric Hematoma of the Small intestine

卵巣腫瘍と術前診断された特発性腸間膜血腫の1例

症例は53歳，女性．1年前に検診時に卵巣腫瘍を指摘されていたが，放置していた．腹痛を契機に近医で精査を受け卵巣腫瘍を疑われ，当院婦人科に紹介された．CT検査，経腟エコー検査で10cmを超える嚢胞性腫瘤を認め，右卵巣腫瘍と診断され手術となった．片側附属器切除予定で開腹したが，両側卵巣は正常で，回腸末端の小腸間膜に腫瘤がみられたため，癒着していた虫垂，回腸とともに切除した．術後病理検査では腸間膜血腫の診断で，腹部外傷，血液疾患，抗凝固薬内服などの既往はなく，特発性腸間膜血腫と診断した．発症から長期間経過しており，骨盤内に存在したため嚢胞性卵巣腫瘍との鑑別が困難であったと考えられた．特発性腸間膜血腫はまれではあるが骨盤内嚢胞性病変の鑑別診断の1つに含まれるべきであると思われた．

Surgical management of early small bowel obstruction after laparoscopic Roux-en-Y gastric bypass

BackgroundLimited data are available regarding early postoperative small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of the present study was to review our experience with early SBO after LRYGB. The setting was a tertiary referral bariatric center. MethodsWe reviewed a prospectively maintained database to assess the diagnosis, management, and outcomes of patients who underwent surgery for SBO within 30 days of LRYGB. ResultsFrom April 2004 to December 2011, 2126 patients underwent LRYGB. Of these patients, 11 (.5%) required surgical management for early SBO. Of the 11 patients, 9 were women and 2 were men. with a mean age of 53 years (range 35–70) and mean body mass index of 45 kg/m2 (range 38–65). The average interval from LRYGB to the presentation of SBO was 5.0 days (range 2–15). All early SBOs were diagnosed by computed tomography with oral contrast. The causes of early SBO included kinking at the jejunojejunostomy in 4, an intraluminal blood clot near the jejunojejunostomy in 2, angulation of the Roux limb in 1, mesenteric hematoma in 1, intra-abdominal hematoma in 1, obstruction of common channel in 1, and pelvic adhesions from previous surgery in 1. Diagnostic laparoscopy was attempted in all patients. Four patients required conversion to open surgery. Postoperative complications developed in 5 patients; no patient died. Laparoscopic management of early SBO resulted in fewer complications than the open approach. ConclusionEarly SBO after LRYGB is uncommon; however, a prompt diagnosis and surgical intervention are important to prevent additional morbidity. The ability to complete the reoperation laparoscopically varies with the etiology and location of the obstruction.

Mesenteric artery complications during angioplasty and stent placement for atherosclerotic chronic mesenteric ischemia

The purpose of this study was to describe the incidence, management, and outcomes of mesenteric artery complications (MACs) during angioplasty and stent placement (MAS) for chronic mesenteric ischemia (CMI). We retrospectively reviewed the clinical data of 156 patients treated with 173 MAS for CMI (1998-2010). MACs were defined as procedure-related mesenteric artery dissection, stent dislodgement, embolization, thrombosis, or perforation. End points were procedure-related morbidity and death. There were 113 women and 43 men (mean age, 73 ± 14 years). Eleven patients (7%) developed 14 MACs, including distal mesenteric embolization in six, branch perforation in three, dissection in two, stent dislodgement in two, and stent thrombosis in one. Five patients required adjunctive endovascular procedures, including in two patients each, catheter-directed thrombolysis or aspiration, retrieval of dislodged stents, and placement of additional stents for dissection. Five patients (45%) required conversion to open repair: two required evacuation of mesenteric hematoma, two required mesenteric revascularization, and one required bowel resection. There were four early deaths (2.5%) due to mesenteric embolization or myocardial infarction in two patients each. Patients with MACs had higher rates of mortality (18% vs 1.5%) and morbidity (64% vs 19%; P <.05) and a longer hospital length of stay (6.3 ± 4.2 vs 1.6 ± 1.2 days) than those without MACs. Periprocedural use of antiplatelet therapy was associated with lower risk of distal embolization or vessel thrombosis (odds ratio, 0.2; 95% confidence interval, 0.06-0.90). Patients treated by a large-profile system had a trend toward more MACs (odds ratio, 1.8; 95% confidence interval, 0.7-26.5; P = .07). MACs occurred in 7% of patients who underwent MAS for CMI and resulted in higher mortality, morbidity, and longer hospital length of stay. Use of antiplatelet therapy reduced the risk of distal embolization or vessel thrombosis. There was a trend toward more MACs in patients who underwent interventions performed with a large-profile system.

Multi Detector Computed Tomography in the Diagnosis of Bowel Injury

Bowel Injuries are uncommonly associated with traumatic abdominal injuries. However, they are associated with significant morbidity and mortality and require operative intervention unlike solid organ injuries. Hence, early diagnosis is of paramount importance. Computed tomographic (CT) scan is a well-established and highly accurate imaging modality for the detection of solid organ injury after blunt abdominal trauma. However, its role in diagnosing hollow viscus injury remains controversial. The aim of our study was to analyze the accuracy of multidetector CT (MDCT) in the diagnosis of bowel injury. Imaging features of surgically proven cases of bowel injury were identified over 8-year period (i.e., from January 2003 to December 2010) and were retrospectively analyzed. There were 32 patients with age range of 3-90years. There was only one female. Sensitivity of various CT signs specific to bowel injury (i.e., extravasation of contrast and discontinuity of bowel wall) was 15.62, and 28.12%, respectively. While that of signs suggestive of bowel injury were pneumoperitoneum, 62.5%; gas in the vicinity, 40.62%; bowel wall hematoma, 21.87%; bowel wall thickening, 75%; ascites, 78.12%; mesenteric hematoma, 46.87%; and mesenteric stranding, 40.62%. Based on the major and minor signs, a diagnosis of bowel injury could be made in all patients except one. The minor signs showed a higher sensitivity than the major signs. Hence, we recommend that multidetector CT should be used as the modality of choice in case of patients with suspected bowel injury. We also suggest that the minor signs should be given as much importance as the major signs.

Infective aneurysm of the inferior pancreaticoduodenal artery

Pancreaticoduodenal (PD) artery aneurysms account for less than 2% of all splanchnic aneurysms. A mycotic aetiology is extremely uncommon. Two weeks following an episode of sepsis related to a prostatic biopsy, a 59-year-old man presented with abdominal pain and anaemia. Ultrasonography and computed tomography revealed an inferior PD artery pseudoaneurysm with an associated mesenteric root haematoma. This was treated successfully by transcatheter embolisation. Infective pseudoaneurysms of the PD artery are rare but can be associated with rupture into the gastrointestinal tract or retroperitoneum. Transcatheter embolisation remains the most effective therapy as it is associated with low morbidity and mortality rates and recurrence is very unlikely provided the aneurysm is completely excluded from the circulation.

Jujitsu Kick to the Abdomen: A Case of Blunt Abdominal Trauma Resulting in Hematochezia and Transient Ischemic Colitis

Blunt abdominal trauma is a common presentation to the emergency department. Ischemic colitis is a rare complication of this and its possible sequelae are important for an emergency physician to recognize. A 21-year-old man presented to the emergency department with abdominal pain and hourly episodes of bright red blood per rectum shortly after being kicked in the stomach at his jujitsu class. He had no significant medical history, and results of his systems review were otherwise unremarkable. On examination, he appeared well, with normal vital signs. He had mild lower abdominal tenderness, but there were no peritoneal signs present. There was blood on the digital rectal examination. His hemoglobin, platelet, and international normalized ratio levels were normal and his abdominal radiograph was unremarkable. The gastroenterology service was contacted because of the hematochezia and a flexible sigmoidoscopy was performed. The sigmoidoscopy showed erythema, ulceration, and edema of a segment in the left colon, consistent with ischemic colitis. This was later confirmed on biopsy. A computed tomography (CT) scan of the abdomen was conducted, which revealed left colonic inflammation consistent with colonic ischemia. There was no mesenteric vascular thrombosis or mesenteric hematoma found on CT. His hematochezia and abdominal pain subsided spontaneously, and he was discharged home. This case illustrates transient ischemic colitis as a potential presentation of blunt abdominal trauma, and emergency physicians should consider this uncommon diagnosis in the differential diagnosis of patients presenting after abdominal trauma.

Hemorrhagic shock caused by sigmoid colon volvulus: An autopsy case

SummaryBackgroundMany reports have described sigmoid volvulus, but fatal hemorrhagic shock resulting from the rupture of the involved artery has not been reported as a complication of a sigmoid volvulus.Case ReportA 71-year-old man with slight abdominal pain and obstipation in hypotension died at a nursing home without seeing a doctor. At autopsy, a mesenteric hematoma and hemoperitoneum was observed with approximately 1,000 ml of blood in the abdominal cavity. The sigmoid colon and the mesentery were twisted at an adhesion site of a sigmoid colon to an ileum, and the condition was determined to be a sigmoid volvulus. The volvulus was observed to be loosened. The inferior mesenteric artery was incorporated into the twisted part of the mesentery, but remained patent, and its peripheral branch near the hematoma ruptured without histological abnormality.ConclusionsSince ischemic-reperfusion injury occurs with a temporarily occluded artery, the acute re-loading of blood flow may injure the distal vessels after spontaneous reduction of compression by loosening of the volvulus.

Massive per rectal bleeding following blunt abdominal trauma: First presentation of Crohn's disease

IntroductionInflammatory bowel disease is a chronic and relatively common disorder with heterogeneous presentation. Peak incidence occurs in the second and third decades of life. We present a patient with Crohn's disease whose first presentation was profuse bleeding/rectum following blunt abdominal trauma. presentation of caseA 29 year old previously healthy man presented one hour after sustaining relatively mild abdominal trauma, due to fall onto the ball during a rugby match. He complained of abdominal pain and one episode of large fresh rectal bleeding. He was pale and distressed with hypotension, tachycardia and abdominal guarding & fresh blood on digital rectal examination. With a provisional diagnosis of intestinal injury he was taken to theatre. Right hemi-colectomy was done for a thickened and inflamed segment of distal ileum, a large adjacent mesenteric haematoma & mesenteric lymph nodes and blood in distal bowel. Histology confirmed the features of Crohn's disease. discussionCrohn's disease is unusual cause of massive lower gastrointestinal bleeding occurring in 0.9–6% of patients. Rectal bleeding associated with diarrhoea is relatively more common than massive bleeding. The presence of Crohn's disease in young patients presenting like this is unlikely to be suspected and diagnosis could only be made after laparotomy.

A Case of Inguinal Hernia Incarceration Complicated by a Mesenteric Hematoma of the Sigmoid Colon

A Case of Inguinal Hernia Incarceration Complicated by a Mesenteric Hematoma of the Sigmoid Colon

Robotic partial nephrectomy in the setting of prior abdominal surgery

• To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct-vision trocar placement. • From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN). • Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally-invasive scar. • Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique. • We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear-tipped trocar. • Lysis of adhesions was performed as needed to allow for placement of additional robotic ports. • A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars. • There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m(2) ), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications. • A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy-2 patients (33%), open partial gastrectomy-2 patients (33%) and exploratory laparotomy-1 patient (17%). • Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy-10 patients (29%), umbilical/inguinal hernia repair-9 patients (26%) and appendectomy-7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement. • Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications. • Direct-vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.

Massive rectal bleeding distant from a blunt car trauma

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.