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Closed abdominal trauma by bull's horn

Author(s)

Jenny S. Cardenas H, Jelena Vucetic, Julio C. Rivera, Rebeca Miron, Gonzalo Sanchez J.

General University Hospital of Valencia, Radiology Department; Avenida Tres Cruces 2 46014 Valencia, Spain; Email: jennysorayacardenas@gmail.com

Patient

male, 50 year(s)

Clinical History

A 50-year-old man with abdominal trauma due to a bull`s horn impact and enolic intoxication presented with diffuse abdominal pain. Physical examination revealed a painful and erythematous mass in the left lower abdominal quadrant with skin integrity, without signs of peritoneal irritation or presence of penetrating abdominal injury. The patient was haemodynamically stable.

Imaging Findings

In an abdominal-pelvic CT examination, there was an abdominal wall herniation containing small intestine loops, along with herniated mesentery and extraluminal air in the herniation margin attributable to intestinal perforation, located between the lateral border of the rectus abdominis and left oblique muscles.
There was trabeculation of the retroperitoneal fat with fluid collection adjacent to the psoas iliacus and in the course of the left ureter, findings suspicious of the ureteral injury. To confirm it, the excretory phase was obtained and it revealed a laceration of the middle third of the left ureter with contrast extravasation through the herniation.

Discussion

In closed abdominal trauma, both intestinal perforation and ureteral laceration and herniation of the abdominal wall are rare lesions and point to a severe contusive mechanism. There are three mechanisms that explain abdominal organ damage: deceleration, external compression and crushing [1, 2, 3].

Intestinal and mesenteric lesions occur in approximately 5% of patients with severe abdominal trauma [1]. In this case the mechanism of injury was the external compression that led to a sudden and abrupt increase of the intra-abdominal pressure causing intestinal perforation. The small intestine is the most frequently affected, followed by the colon and stomach [1]. The CT examination is used for a rapid and accurate diagnosis in these patients. Extraluminal air is a finding with a specificity of 95%, but is not pathognomonic for the diagnosis of intestinal perforation (sensitivity of 30-60%), therefore it is important to take into account other related imaging findings such as thickening of the intestinal walls and alteration of mesenteric fat [1, 5].

Blunt ureteral and ureteropelvic junction injuries are rare and difficult to diagnose [7], it requires a mechanism of rapid deceleration and ureteral hyperextension that causes an increase in tension and subsequent laceration or avulsion of the ureter, mainly at the points of fixation along its path, such as ureterovesical and ureteropelvic junction [6, 8]. In our case, a complete lesion of the middle ureter is observed, which presents with a frequency of 31% according to reports [8].
Delayed contrast CT imaging is the technique of choice for the evaluation of urinary tract trauma. The exam is performed according to specific indications such as: haematuria and injuries that associate renal damage, like rapid deceleration, fall from height, direct contusion or haematoma in the flank, fractures of the lower ribs or thoracolumbar spine, independently of the presence of haematuria [6]. There are subtle findings suggesting ureteral injury: low density fluid located around the kidneys and ureters (as seen in our case) and perinephric haematomas [7]. It is crucial to differentiate a total ureteral avulsion requiring surgical treatment from an incomplete rupture in which conservative treatment is indicated [1].

The traumatic abdominal wall hernia is defined as a herniation through the muscles and disruption of abdominal fascia, without penetrating wound or presence of a previous hernia defect at the site of injury [4]. The injury mechanism consists of the application of external forces on the abdominal wall and shear forces that are distributed throughout the abdominopelvic cavity [3, 4]. A CT examination helps to assess complications such as obstruction, incarceration, and strangulation [5].

Final Diagnosis

Differential Diagnosis List

References

[1]

Jorge A. Soto, MD Stephan W. Anderson, MD (2012) Multidetector CT of Blunt Abdominal Trauma.. Radiology Volume 265: 678-693
[2]

T.M.D. Hughes∗, C. Elton (2002) The pathophysiology and management of bowel and mesenteric injuries due to blunt trauma.. Injury 33;295–302
[3]

Belgers HJ, Hulsewé KW, Heeren PA, Hoofwijk AG. (2005) Traumatic abdominal wall hernia: delayed presentation in two cases and a review of the literature.. Hernia 9(4):388-91.
[4]

Damschen DD, Landercasper J, Cogbill TH, Stolee RT. (1994) Acute traumatic abdominal hernia: case reports.. J Trauma. Vol36(2):273-6.
[5]

Virmani V1, George U, MacDonald B, Sheikh A. (2013) Small-bowel and mesenteric injuries in blunt trauma of the abdomen.. Can Assoc Radiol J 64(2):140-7
[6]

Alonso RC1, Nacenta SB, Martinez PD, Guerrero AS, Fuentes CG. (2009) Kidney in danger: CT findings of blunt and penetrating renal trauma.. Radiographics 29(7):2033-53
[7]

Ortega SJ, Netto FS, Hamilton P, Chu P, Tien HC. (2008) CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries.. BMC Urol. 8:3: 1-5
[8]

Elliott SP, McAninch JW (2006) Ureteral injuries: external and iatrogenic.. Urol Clin North Am Feb;33(1):55-66, vi

Citation

Jenny S. Cardenas H, Jelena Vucetic, Julio C. Rivera, Rebeca Miron, Gonzalo Sanchez J. (2017, Oct 7).

Closed abdominal trauma by bull's horn, {Online}.

URL: http://www.eurorad.org/case.php?id=14944

DOI: 10.1594/EURORAD/CASE.14944

ISSN: 1563-4086

Public License

This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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Published 07.10.2017
DOI 10.1594/EURORAD/CASE.14944
Section Abdominal Imaging
Case Type Clinical Cases
Views 485
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Figure 1
Traumatic abdominal hernia with soft tissue emphysema

a

Department of Radiology. General University Hospital of Valencia. Valencia-Spain

b

Department of Radiology. General University Hospital of Valencia. Valencia-Spain

c

Department of Radiology. General University Hospital of Valencia. Valencia-Spain

Herniation between the lateral border of the rectus abdominis and left oblique muscles (white arrow) with small intestine loops inside (yellow arrow). Herniated mesenteric tissue and extraluminal air in the...

Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;

In addition, it has fluid collected in the peritoneal cavity and inside the hernia (orange arrows).

Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;

Herniation between the lateral border of the rectus abdominis and left oblique muscles (white arrow) with small intestine loops inside (yellow arrow). Herniated mesenteric tissue and extraluminal air in the...

Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;
Figure 2
Suspected ureteral injury

There is trabeculation of the retroperitoneal fat with fluid collection adjacent to the psoas iliacus and in the course of the left ureter, findings suspicious of the ureteral injury (white arrow).

Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;
Figure 3
Ureteral injury

a

General University Hospital of Valencia. Department of Radiology. Valencia-Spain.

b

General University Hospital of Valencia. Department of Radiology. Valencia-Spain.

Ureteral injury was suspected, and late contrast study is performed, revealing the laceration of the middle third of the left ureter (yellow arrow) with extravasion of excreted contrast through the herniation (red...

Area of Interest: Urinary Tract / Bladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;

Ureteral injury was suspected, and late contrast study is performed, revealing the laceration of the middle third of the left ureter (yellow arrow) with extravasion of excreted contrast through the herniation (red...

Area of Interest: Urinary Tract / Bladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;
Figure 4
Ureteral injury

a

Department of Radiology. General University Hospital of Valencia. Valencia-Spain

b

Department of Radiology. General University Hospital of Valencia. Valencia-Spain

Complete ureteral laceration with extravasation of contrast (red arrows).

Area of Interest: Urinary Tract / Bladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;

3D reconstruction shows complete ureteral laceration (red circle).

Area of Interest: Urinary Tract / Bladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Trauma;

Figure 1

Traumatic abdominal hernia with soft tissue emphysema

Figure 1a

Herniation between the lateral border of the rectus abdominis and left oblique muscles (white arrow) with small intestine loops inside (yellow arrow). Herniated mesenteric tissue and extraluminal air in the eventration margin (blue arrow).

Figure 1b

In addition, it has fluid collected in the peritoneal cavity and inside the hernia (orange arrows).

Figure 1c

Figure 2

Suspected ureteral injury

There is trabeculation of the retroperitoneal fat with fluid collection adjacent to the psoas iliacus and in the course of the left ureter, findings suspicious of the ureteral injury (white arrow).

Figure 3

Ureteral injury

Figure 3a

Ureteral injury was suspected, and late contrast study is performed, revealing the laceration of the middle third of the left ureter (yellow arrow) with extravasion of excreted contrast through the herniation (red arrow).

Figure 3b