Canadian Association of Radiologists Journal 66 (2015) 158e163

www.carjonline.org

Trauma and Emergency Room Imaging / L’imagerie des urgences et des traumatismes

Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries

in Patients With Blunt Chest and Abdominal Trauma
Nima Kokabi, MDa,*, Elie Harmouche, MDa, Minzhi Xing, MDa, Waqas Shuaib, MDa,
Pardeep K. Mittal, MDa, Kenneth Wilson, MDb, Jamlik-Omari Johnson, MDa,
Savvas Nicolaou, MDc, Faisal Khosa, MDa
a
Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
b
Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
c
Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada

Abstract
Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of
trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in
detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This
pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and
abdominal trauma.

Resume
Les lesions aux visceres creux du systeme gastro-intestinal consecutives a un traumatisme thoracique et abdominal ne sont pas courantes:
elles n’aggravent que de 0,6 a 1,2 % des traumatismes. Toutefois, leur detection precoce reduit considerablement le taux de morbidite et de
mortalite. Puisque l’examen physique ne permet pas de deceler efficacement ce type de lesions, de nombreux services d’urgence ont recours a
la tomodensitometrie avec injection de produit de contraste pour poser un diagnostic. Cet essai descriptif vise a analyser l’incidence des
lesions aux visceres creux du systeme gastro-intestinal, ainsi que les mecanismes et les signes qui leur sont associes, dans un contexte de
traumatisme contondant au thorax et a l’abdomen.
Ó 2015 Canadian Association of Radiologists. All rights reserved.

Key Words: Hollow viscus injury; Gastrointestinal tract; Blunt trauma; Computed tomography

Trauma is the leading cause of death in individuals under
the age of 45 years and the fourth leading cause of death for
all ages [1]. The death rate due to trauma was 180,000 in
2007 within the United States alone [1]. The incidence of
hollow viscus injury (HVI) following blunt abdominal
trauma (BAT) and chest trauma is between 0.6%-1.2%, and
5% with severe BAT [1e5]. Contrast-enhanced computed
tomography (CECT) is the diagnostic modality of choice in
the assessment of hemodynamically stable patients with
blunt chest and abdominal trauma [2]. Timely identification
* Address for correspondence: Nima Kokabi, MD, Department of
Radiology and Imaging Sciences, Emory University Hospital Midtown, 550
Peachtree Street NE, Atlanta, Georgia 30308, USA.
E-mail address: nima.kokabi@emory.edu (N. Kokabi).
of such injuries on CT is crucial for patient management and
prognosis [6]. This review aims to identify general and
specific radiological signs of gastrointestinal HVI in patients
with blunt chest and abdominal trauma, with a focus on
CECT findings. In addition, the epidemiology, mechanism of
injury, and management of such injuries is briefly reviewed.
General Findings
Although a variety of imaging signs are usually present in
HVI, more specific findings may not be sensitive and the
more sensitive signs are not highly specific [1]. For example,
for an average-size patient, collimation of 1.25 mm (4-slice
and 16-slice) or 0.6 mm (64-slice), 120 kVp, and 300 mA
may be appropriate [7], however, the use of dynamic scan

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 HVI in BAT / Canadian Association of Radiologists Journal 66 (2015) 158e163 159

parameters to reduce radiation dose and accommodate for

body size are strongly advised and should be in line with the
ALARA principle (As Low As [is] Reasonably Achievable)
principle. As a primary screening study, a single portal
venous phase examination is usually sufficient. In specific
circumstances such as suspected bowel perforation, delayed
phase examination with oral contrast may increase sensitivity
and specificity of findings (ie, pooling of contrast material
outside of the lumen).

Pneumoperitoneum

Although free air in the peritoneal cavity is sensitive for

HVI, it may not be specific for the diagnosis of small bowel
injury (SBI). A study of 275,557 trauma admissions with
HVI following BAT found that pneumoperitoneum on CT
scan was pathognomonic for HVI (91.5%) but was not
discriminating for SBI, as only 43.8% of the patients with
pneumoperitoneum had a perforated SBI, and the rest had
other HVI [8]. Lung window greatly increases the sensitivity
of detecting small pneumoperitoneum [1]. Pneumo-
peritoneum should be distinguished from pseudopneumo-
peritoneum (collection of air between the abdominal wall
and peritoneum), as the latter may be a false-positive and Figure 1. Esophageal perforation with extraluminal fluid and pneumo-
may be caused by rib fracture, pneumothorax, pneumo- mediastinum (arrows) (A) tracking into the base of the neck (B). Incidental
mediastinum, and extraperitoneal rectal injury [1]. left posterior third rib fracture (red arrow) and right pectoralis muscle he-
matoma/edema (*) noted. This figure is available in colour online at http://
carjonline.org/.
Free Fluid

Hematoma between bowel loops often indicates an injury Esophagus

to the bowel or mesentery, as blood from solid organ lacer-
ation frequently collects within the subdiaphragmatic spaces,
paracolic gutters, or pelvis [9]. Hemoperitoneum is seen as
an intermediate attenuation fluid (>25 Hounsfield units
[HU]). Oral contrast is rarely used in trauma scans, with the
exception of low-acuity scans or rescanning to clarify if HVI
is present. Leaking oral contrast hyperattenuates on CT
(>150 HU), similar to fluid seen with active arterial bleeding
(with a similar attenuation to major arteries). Hypo-
attenuating fluid (<20 HU) in the setting of HVI usually
indicates small bowel injury [9].
Bowel Wall Findings
Intramural hematoma results in circumferential or
eccentric thickening of the bowel wall, and is an indicator of
blunt trauma to the bowel wall. Intense focal enhancement
suggests bowel injury or perforation if associated with free
peritoneal fluid, while diffuse bowel wall enhancement can
be seen with shock [9].
Mesenteric Injury
Presence of mesenteric hematoma may indicate the
presence of a bowel injury or mesenteric vessel laceration.
The sentinel sign (presence of higher attenuation of blood
near the site of injury) is a strong evidence for HVI [9].
Esophageal injury occurs in 1% of blunt chest and
abdominal trauma and typically involve the cervical and upper
thoracic parts of the esophagus [10]. Esophageal injuries in
general are rare, mainly due to the small size of the esophagus,
its relatively protected position, and to the fact that a significant
number of patients with esophageal injuries will often suc-
cumb secondary to associated vascular injuries [11]. Mortality
for esophageal trauma ranges from 0%-22% [11].
The underlying mechanisms of injury are shearing force
secondary to rapid acceleration/deceleration, increased intra-
luminal pressure with closed glottis, direct blow to the neck,
hyperextension, and rupture by a vertebral body fracture [10].
Diagnosis requires a high index of suspicion as it relies mainly
on the presence of indirect radiological signs [11]. Subcutane-
ous, muscular thoracic or cervical emphysema, abnormal
course of a nasogastric tube, widened mediastinum, pneumo-
mediastinum, pneumopericardium, left-sided pneumothorax,
pleural effusion, and left lower lobe atelectasis may be seen on
CECT [11]. More specific signs include localized esophageal
wall thickening, mucosal hyperemia, mucosal dissection,
esophageal hematoma, and edema [10,11] (Figure 1).
Esophageal injuries are associated with mediastinitis,
periesophageal fluid, extraluminal gas, pleural effusions, and
possible contrast extravasation. Mucosal lacerations, most
intramural hematoma, some cervical, and contained perfo-
rations can be managed conservatively [10]. Uncontained
160 N. Kokabi et al. / Canadian Association of Radiologists Journal 66 (2015) 158e163

Figure 2. Severely distended stomach with intraluminal heterogeneous dense material (white arrows) and active extravasation (red arrows). No pneumoperitoneum.
Contained rupture with large amount of intraluminal hemorrhage found during surgery (A-D). This figure is available in colour online at http://carjonline.org/.

transmural perforation is generally treated via surgical
debridement, primary closure, and mediastinal drainage. In
critical patients or those at high risk for surgery, esophageal
exclusion and diversion is the most prudent option [10].
Stomach
Gastric injuries occur in 0.4%-1.7% of all BAT and are the
third most common HVI after the small bowel and colon [1].
Gastric injuries are commonly seen in younger populations
and have the highest mortality compared to other HVI
(28.2%) [12]. The main mechanism of injury is significant
blunt force on a distended stomach, especially after a recent
meal. Motor vehicle accidents are the main source of gastric
injuries, particularly if they involve trauma to the left side of
the chest or use of lap belts [13]. The main mechanism of
injury is tearing by deceleration. The most commonly
affected areas are the anterior wall, followed by the greater

Figure 3. Duodenal perforation. Thickened heterogeneously enhancing duodenal wall with extraluminal fluid (white arrows) and air (yellow arrow) on initial
contrast-enhanced computed tomography (CECT) (A, B). Leaking of oral contrast and pooling around the duodenum on follow-up exam (white arrows) (C, D).
This figure is available in colour online at http://carjonline.org/.
 HVI in BAT / Canadian Association of Radiologists Journal 66 (2015) 158e163 161

Figure 4. Mesenteric hematoma with ischemic injury to jejunum and ileum with hyperdense fluid (yellow arrows) within the mesentery and bowel wall thickening
(white arrows) more prominent in areas of mesenteric hematoma (A, B). Normal appearing more distal small bowel (blue arrows). Multiple corresponding
segments of bowel were found to be ischemic during exploratory laparotomy. This figure is available in colour online at http://carjonline.org/.

curvature, lesser curvature and the posterior wall [9]. The
most commonly associated injuries include those to the
spleen and thorax [13].
CECT may show nonspecific signs such as free intra-
abdominal fluid, or more specific signs such as a distended
stomach, extraluminal gas or oral contrast, and intramural
hematoma [13] (Figure 2). Management is typically con-
servative for cases with wall thickening and mural hema-
toma. More severe injuries such as perforation or active
extravasation are managed surgically [13].
Small Bowel
Duodenum
Duodenal contusion is suspected if there is wall thick-
ening (>4 mm), high-density intramural hematoma, or
edema. Presence of focal wall discontinuity, periduodenal
fluid, perirenal fluid/gas, or extraluminal gas in the retro-
peritoneum is suggestive of duodenal perforation. Extra-
luminal pooling of oral contrast or active extravasation from
the gastroduodenal artery may be seen [1,9] (Figure 3).
Pancreatic head or duct involvement, major vessel or biliary
tree injuries are associated injuries.
Management of isolated duodenal hematomas is usually
conservative, although gastric outlet obstruction syndrome
may develop in the early stages. Surgical management is
reserved for more severe injuries such as perforation,
pancreatic head involvement or duct, major vessels, or biliary
tree injuries.

SBIs following BAT are common, with an incidence of Jejunum/Ileum

5%-15% in BAT, comprising at least 50% of all HVI cases
[14]. The incidence of perforation in blunt trauma is 0.3%
[12]. Isolated duodenal injuries secondary to (BAT) are un-
common [1]. Duodenal injuries have the lowest mortality for
blunt HVI (14.8%) [12]. Shearing forces contribute to
duodenal injuries. Hematoma and perforation occur most
commonly in the descending and horizontal segment of the
duodenum, as the latter crosses next to the spine and is easily
compressed by vertebral bodies.
Jejunal and ileal injuries are less common than duodenal
injuries and have a mortality rate of 15% [12]. The jejunum and
ileum are generally injured near a point of fixation such as the
ligament of Treitz and ileocecal valve. These points of fixation
allow the more mobile loop to be injured by shearing forces.
The portion of jejunum just distal to the ligament of Treitz,
distal ileum proximal to the ileocecal valve, and duodenoju-
jenal flexure are particularly susceptible [9,15]. Other

Figure 5. Traumatic herniation (yellow arrows) of descending colon posterior to the left lateral abdominal muscles with mildly thickened bowel wall (A, B). There
is also fluid present in the herniation sac better appreciated on coronal reformats (*). This figure is available in colour online at http://carjonline.org/.
162 N. Kokabi et al. / Canadian Association of Radiologists Journal 66 (2015) 158e163
Figure 6. Traumatic colonic rupture involving the cecum with pneumoperitoneum (white arrows) and retroperitoneum, free fluid, and stranding (yellow arrows)
(A, B). This figure is available in colour online at http://carjonline.org/.
mechanisms of injury include crushing forces of the bowel
against the spine. In particular, a Chance fracture and/or
seatbelt sign should raise suspicion for SBI [5]. Associated
mesenteric tears causing a compressive hematoma can
compromise blood supply and lead to bowel infarction
(Figure 4). Rupture occurs most commonly on the anti-
mesenteric border [9]. CT findings include bowel wall hema-
toma and thickening of >4 mm. Extraluminal free fluid
(typically hypoattenuating, <20 HU) may be commonly seen.
Because small bowel does not typically contain gas, perfora-
tion may occur in the absence of pneumoperitonium [9].
Peritoneal irritation develops slowly as the contents in the
small bowels have neutral pH, are enzymatically inactive and
have a low bacterial count [16,17]. Use of oral or rectal contrast
in BAT has been questioned as it poses a risk of aspiration, as
well as slow progression due to paralytic ileus resulting in an
estimated wait of >90 minutes for adequate opacification of
the bowels, while hindering the detection of intraluminal
hemorrhage [15,18].
Management is conservative for intramural hematoma
without perforation. Exploratory laparotomy is required for sus-
pected perforation, vessel injury, or risk of bowel ischemia [12].
Colorectal
Blunt colorectal injury is rare with an incidence of 0.3%
and is seen in 1%-5% of BAT cases [6] and has the second
highest mortality rate in HVI (19.4%) [12]. Colorectal in-
juries are generally caused by compression of the upper
abdomen by lap belts or a steering wheel. Main mechanisms
of injury are shearing and crushing forces. The transverse
colon, sigmoid colon and cecum are the most common site of
injury [9]. Injuries to the transverse colon usually involve
intramural hematoma and lacerations or serosal tears without
fecal spillage. Severe injury such as avulsion of the mesen-
tery, full thickness laceration, transection, and devasculari-
zation are more commonly seen in the ascending and
descending colon [9]. Traumatic herniation of the transverse
colon through a diastasis of the rectus abdominis muscle, or
herniation of the ascending or descending colon behind the
lateral abdominal muscles may be observed [9] (Figure 5).
On CT, the presence of focal wall discontinuity, extravasa-
tion of oral contrast and intraperitoneal air may indicate
bowel perforation. Free retroperitoneal air may be identified
indicating an injury to the ascending and descending colon or
rectum if found in the pelvis. Free retroperitoneal air is less
commonly found as an isolated finding and is not specific for
colonic injury as it may indicate duodenal perforation,
pneumothorax, or pneumoemediastinum [14]. Pericolonic
and mesocolic fat stranding may be seen on CT (Figure 6).
Unlike SBIs, blunt colonic injuries often require prompt
surgical intervention, as patients with colon injury are at high
risk for serious complications such as abscess or sepsis, as well
as increased hospital stay [6]. Furthermore, a delay in surgery
of more than 6 hours in patients with uncontrolled colonic
injury has been previously found to be a predictor of poorer
outcomes [19,20]. Because no individual test or combination
of diagnostic modalities in current use adequately detects
colonic injury [6], timely referral for operative management in
cases of suspected colonic injury is crucial in reducing surgical
delay and preventing complications.
Conclusion
Although HVI secondary to BAT are relatively uncom-
mon, timely diagnosis is essential for appropriate manage-
ment of trauma patients, as delays may result in increased
morbidity and mortality. Radiologists must be familiar with
the appearance of HVI on CT and have a high index of
suspicion, as diagnosis often relies on secondary rather than
organ-specific signs.
Acknowledgements
Faisal Khosa is an American Roentgen Ray Scholar.
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