AJR 2002; 178:403-404
© American Roentgen Ray Society
Using CT to Reveal Traumatic Ischemic Stricture of the Terminal Ileum
C. Lee-Elliott1,
W. Landells2 and
A. Keane1
1
Department of Radiology, St. Helier Hospital, Wrythe Ln., Carshalton, Surrey
SM5 1AA, United Kingdom.
2
Department of Pathology, St. Helier Hospital, Carshalton, Surrey SM5 1AA,
United Kingdom.
Received April 16, 2001;
accepted after revision June 11, 2001.
Address correspondence to A. Keane.
Introduction
Traumatic ischemic strictures of the small bowel are rare
[1], and few reported cases are
found in the English literature. These strictures are important to recognize,
because they can have presentation and imaging features identical to Crohn's
disease [1]. We present a case
of posttraumatic ischemic stricture of the terminal ileum and highlight the
value of CT in the diagnosis of small-bowel obstruction.
Case Report
A 29-year-old man was admitted to our institution after a high-speed motor
vehicle crash. He had a fractured shaft of the femur and stable fractures of
the lumbar spine. During his 2-week hospitalization for the insertion of an
intramedullary femoral nail, the patient complained of pain in the right iliac
fossa. This pain was treated conservatively and was resolving on discharge. He
underwent no imaging investigations for the abdominal pain during his
stay.
Three months later, the patient returned with worsening abdominal pain,
intermittent vomiting, and weight loss of 18 kg (40 lb). Unenhanced abdominal
radiography showed multiple dilated loops of small bowel
(Fig. 1A). CT of the abdomen
was performed to look for a cause and to confirm the level of obstruction.
Findings showed multiple dilated loops of jejunum and ileum, which ended at a
narrowed and thickened segment of terminal ileum approximately 18 cm in length
(Figs.
1B,1C,1D).
The imaging features of this abnormal segment of bowel were thought to be most
in keeping with Crohn's disease. However, the patient's inflammatory markers
(erythrocyte sedimentation rate and C-reactive protein) were normal and thus
the possibility of the stricture being related to his recent motor vehicle
crash was also considered.
The obstruction did not resolve with conservative treatment. Two weeks
later, the terminal ileum was resected. Macroscopically, the ileum showed a
nonspecific inflammatory fibrous stricture that included mucosal ulceration
and exudate. Mesenteric induration and enlarged lymph nodes were present. No
evidence of Crohn's disease was found at histology, but recent mesenteric
vascular damage and consequent fibrosis were present. The appearances were
that of an ischemic small-bowel stricture. The patient made an uneventful
recovery and remained healthy at 6-month follow-up.
Discussion
A 1967 review of the world literature found only 48 case reports of
traumatic ischemic stricture since 1901
[2]. To our knowledge, few
cases have been described more recently
[1,2,3,4,5];
most resulted from motor vehicle crashes and involved injuries caused by a
seat belt or steering wheel. The clinical presentation and imaging features of
traumatic ischemic stricture can be identical to Crohn's disease
[1]. These strictures are
thought to result from mesenteric trauma caused by deceleration and shearing
injury, with consequent artery wall damage leading to local ischemia,
fibrosis, and ileal stenosis
[3], or from thrombosis of
mesenteric end arteries [4].
The first mechanism is thought to be responsible in this patient. Other
reported mechanisms of posttraumatic small-bowel obstruction are small
localized perforations leading to delayed abscess formation and subsequent
obstruction [5] and intramural
hematomas exciting a fibroblastic reaction
[6].
The diagnosis of small-bowel obstruction is often made on clinical grounds
and confirmed on unenhanced abdominal radiography. If doubt exists,
radiographic contrast studies of the small bowel can reveal the presence and
level of obstruction. However, this technique poses problems in cases of
high-grade obstruction, in which the passage of barium is considerably
delayed; further-more, the study does not show the extraluminal anatomy. CT
has been shown to be superior to radiography in detecting the presence of
obstruction in the small bowel and determining the level of obstruction
[7]. In addition, CT can reveal
a causative malignant or inflammatory mass and show the length of the
strictures [8]. Strangulation,
internal herniation, volvulus, or other causes of small-bowel ileus such as
infarction will also be visible on CT
[7]. When no other cause is
found, obstructions due to adhesions are inferred.
In conclusion, in cases of small-bowel obstruction in which the patient has
a history of considerable blunt abdominal trauma, however remote, the
diagnosis of traumatic ischemic stricture should be considered even if the
imaging findings suggest Crohn's disease. This case demonstrates the
usefulness of CT in the diagnosis and evaluation of acute small-bowel
obstruction.
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Introduction
Case Report
