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Dilemma of Blunt Bowel Injury: What Are the

Factors Affecting Early Diagnosis and Outcomes
AMMAR AL-HASSANI, M.D.,* MAZIN TUMA, M.D.,* ISMAIL MAHMOOD, M.D.,* IBRAHIM AFIFI, M.D.,*
AMMAR ALMADANI, M.D.,* AYMAN EL-MENYAR, M.D., AHMAD ZAROUR, M.D.,* MONIRA MOLLAZEHI,*
RIFAT LATIFI, M.D.,* HASSAN AL-THANI, M.D.*

From the *Section of Trauma and Clinical Research, Trauma Surgery Section, Hamad General Hospital,
Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar; and the
Department of Surgery, University of Arizona, Tucson, Arizona

Blunt bowel and mesenteric injury (BBMI) is frequently a difficult diagnosis at initial presen-
tation. 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 De-
cember 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
x2, Students 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 6 9.5 years. Polytrauma and isolated bowel injury were identified in 53 and 42 per cent, re-
spectively. Mean Injury Severity Score (ISS) was higher in Group A in comparison to Group B
(18 6 11 vs 13 6 8; P 5 0.02). Presence of pain and seatbelt sign (P 5 0.02) were evident in Group B.
Hypotension (P 5 0.004) and hypothermia (P 5 0.01) were prominent in Group A. The rate of
positive Focused Assessment Sonography for Trauma was greater in Group A (P 5 0.001). Among
operative findings, bowel perforation was more frequent in Group B (P 5 0.04), whereas mes-
enteric full-thickness hematoma was significantly higher in Group A. Pelvic fracture was more
frequent finding in Group A (P 5 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 injury (BBMI) is fre-
B LUNT BOWEL AND
quently a difficult diagnosis at initial presenta-
tion. Although small bowel rupture has been reported
to be the third most common injury in blunt abdom-
inal trauma (BAT), the absolute rate of occurrence is
not well known.1 The consequences of missed bowel
injury are significant and associated with higher mor-
bidity and mortality.24 In a multicenter study of 198
patients, 8-hour delay in the diagnosis from the time
of injury to definitive surgical therapy was associated
with increased morbidity and mortality.2 Other inves-
tigators, however, have disputed this association.5, 6
A universal diagnostic approach has not been widely
adopted for screening of BBMI. Physical examination
is often compromised in patient with multiple injuries
and may be unreliable.3 Moreover, the early optimal
Address correspondence and reprint requests to Ammar Al-
Hassani, M.D., Section of Trauma Surgery, Department of Sur-
gery, Hamad General Hospital, P.O. Box 3050, Doha, Qatar. E-mail:
TraumaResearch@hmc.org.qa, ammar_alhassani@yahoo.com.
diagnosis of BBMI remains controversial even after the
liberal use of abdominal imaging technology.7 At least
two studies have shown that neither computed tomog-
raphy (CT) scanning nor Focused Assessment Sonogra-
phy for Trauma (FAST) achieved 100 per cent positive
predictive value in patients who underwent a non-
therapeutic laparotomy after a positive imaging study.8, 9
The most common CT findings for BBMI include
intraperitoneal free air, extravasation of contrast mate-
rial, bowel wall thickening, intraperitoneal free fluid
without solid organ injury (SOI), mesenteric infiltration,
and the presence of intramural air.1012 However, it is
generally accepted that the thickening of bowel wall
alone is not significant in the diagnosis of BBMI and
CT scan has low sensitivity in diagnosing small bowl
perforation.13 The presence of a trace amount of free
fluid without SOI can be managed nonoperatively, pro-
vided that such patients had been examined carefully
for the initial 48 hours.14
With all of these challenges and controversies, the
current study was designed to evaluate the predictors

922
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No. 9 TRAUMATIC BOWEL INJURY
for early diagnosis in addition to the clinical outcomes
of BBMI.
Methods
This is a retrospective analysis including all patients
with BBMI admitted to the Level I trauma center at
Hamad General Hospital (HGH) in Qatar between
January 2008 and December 2011. Data collection in-
cluded patients demographics (age, gender, and na-
tionality), mechanism of injury, Abbreviated Injury
Score (AIS), Injury Severity Score (ISS), hospital
length of stay (LOS), associated injuries, morbidity,
and mortality. Patients were divided into two groups,
i.e., early group (Group A) surgically treated less than
8 hours from injury to operative intervention and
delayed group (Group B) whose treatment was delayed
for greater than 8 hours. All patients (older than 14
years of age) who sustained BAT and suspected to have
bowel injury were included. Patients with penetrating
trauma were excluded from the study.
Patients were evaluated using a combination of
physical examination (using Advanced Trauma Life
Support guidelines) and radiological assessment (chest
radiograph and CT). Based on the initial evaluation
and diagnosis, patients underwent either early surgery
or delayed intervention. The present study was ap-
proved by the Institutional Review Board of HGH.
Ethical clearance was obtained from Medical Re-
search Committee, Hamad Medical Corporation, for
the analysis and publication of this study (Institutional
Review Board #10061).
Statistical Analysis
Data were presented as proportions, mean standard
deviation, and range as appropriate. Baseline demo-
graphic characteristics, presentation, management, and
outcomes were compared between the two groups
using the Students t test for continuous variables and
Pearsons x2 test for categorical variables. Multivariate
logistic regression analysis was performed for the pre-
dictors of mortality after adjustment for relevant cova-
riates. Adjusted odds ratios, with accompanying 95
per cent confidence intervals, were reported for the
respective groups. A significant difference was con-
sidered when the P value (two-tailed) was < 0.05. All
data analyses were carried out using the Statistical
Package for Social Sciences version 18 (SPSS Inc.,
Cary, NC).
Results
Of the 984 patients admitted with BAT, 109 (11%)
patients with bowel injury were included in this study.
? Al-Hassani et al. 923
This constituted approximately 1.7 per cent of the
total blunt trauma admission (6543) during 4 years.
The majority of patients were young males (98%)
with a mean age of 35 9.5 years. The most com-
mon cause of injury was motor vehicle crash (52%)
followed by fall of heavy objects (16%), pedestrian-
related injuries (16%), and fall from a height (14%)
(Table 1). Isolated bowel injury was diagnosed in
42 per cent; however, 53 per cent patients with bowel
injuries had polytrauma. Overall ISS was 16 10
and was significantly higher in Group A (18 11 vs
13 8; P 4 0.02). Median abdominal AIS was 3
ranging from 2 to 5. The overall hospital mortality
was 15.6 per cent, whereas mortality in 8 per cent
of cases was reported within 24 hours of admission
(Table 1). Based on the time from injury to operative
interventions, patients were classified into two groups.
Eighty-three patients (77%) were treated in less than
8 hours postinjury (early group or Group A) and the
remaining 26 (33%) were in the delayed group with
8 hours or greater (Group B). Presence of pain on
admission (70 vs 90%; P 4 0.03) and seatbelt sign
(26 vs 62%; P 4 0.02) were clinically significant in
Group B (Table 2). Other clinical parameters such as
low blood pressure (P 4 0.004) and hypothermia or
body temperature less than 36C (P 4 0.01) were
significant among patients in Group A. The presence
of positive FAST was statistically significant in Group
A (56 vs 16%; P 4 0.001). None of the CT findings
were statistically significant between the two groups,
except mesenteric hematoma, which was more common
in Group A (46 vs 17%; P 4 0.03) (Table 2).
Among operative findings, bowel perforation was
statistically significant in Group B patients (P 4 0.04),
whereas mesenteric full-thickness tear was significantly
high in Group A (P 4 0.009; Table 3). Of the asso-
ciated injuries, pelvic fracture was significantly higher
TABLE 1. Baseline Patient Characteristics
(n 4 109)
Age (years SD) 35 9.5
Males 98%
MVC 52%
Fall of heavy objects 16%
Fall from height 14%
Pedestrians 16%
Time from injury to OR (hours) 4.5 (150)
Time from TRU arrival to OR (hours) 3 (148)
Isolated bowel injury 42%
Polytrauma 53%
ISS 16 10
Abdominal AIS 3 (25)
Overall mortality 15.6%
Morality less than 24 hours 8%
SD, standard deviation; MVC, motor vehicle crash; OR,
operating room; TRU, trauma resuscitation unit; ISS, Injury
Severity Score; AIS, Abbreviated Injury Score.
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924 THE AMERICAN SURGEON September 2013 Vol. 79

TABLE 2. MOI, Clinical Presentation, and Radiologic TABLE 3. Operative Findings, Complications, and
Findings Management
Group A Group B Group A Group B P
(n 4 83) (n 4 26) P (n 4 83) (n 4 26) Values
(77%) (23%) Values
Operative findings
Age 36 10 33 8 0.08 Perforation of small 12% 28% 0.04
MVC 53% 52% 0.45 bowel (SB)
Fall of heavy objects 16% 12% Large bowel (LB) 4% 0%
Fall from heights 11% 24% Multiple 9% 16%
Others 20% 22% Devascularization SB 18.5% 8% 0.64
Clinical findings LB 8.6% 12%
Pain 70% 96% 0.03 Transaction of bowel 11% 12% 0.92
Tenderness 74% 96% 0.06 Serosal tear 31% 32% 0.62
Diffuse tenderness 45% 44% 0.19 Mesenteric partial tear 12.3% 16% 0.35
Localized tenderness 40% 52% 0.18 Mesenteric full-thickness 38% 8% 0.009
Seatbelt sign 26% 62% 0.02 tear
All bruises 57% 52% 0.67 Mesenteric full-thickness 40% 76%
GCS 14 3 15 1 0.21 none
ISS 18 11 13 8 0.02 Isolated bowel injury 37% 60% 0.04
Abdominal AIS 2.7 0.8 2.6 0.7 0.44 Isolated abdominal injury 42% 60% 0.11
Time from arrival to OR 2.5 1.3 16 12 0.001 Associated injuries
Heart rate 97 24 96 17 0.75 Polytrauma 58% 40% 0.11
Systolic blood 106 32 125 14 0.004 Pelvic injury 32% 4% 0.005
pressure (mmHg) Rib fractures 30% 12% 0.07
Diastolic blood 63 23 75 10 0.02 Vertebral injury 21% 8% 0.14
pressure (mmHg) Extremities 32% 40% 0.46
Temperature (C) 36 0.6 37 0.8 0.01 Head injury 16% 8% 0.31
White blood cell count 16 7 19 7 0.08 Treatment 0.16
Base deficit 6 5 4 3.5 0.03 Nontherapetic laparotomy 4% 8%
Serum lactate 4.8 3 4.8 4 0.94 Suturing without resection 48% 48%
Positive FAST 56% 16% 0.001 Resection and anastomosis 33% 44%
CT findings Resection without 15% 0%
Free air 27% 17% 0.31 anastomosis
Free fluids 95% 93% 0.06 Complications (overall) 25% 40% 0.23
Solid organ injury 27% 12% 0.11 Wound infection 10% 24%
Bowel wall thickening 20% 33% 0.73 Wound dehiscence 6% 4%
Fatty strands 32% 25% 0.54 Anastomotic leak and fistula 4% 0
Mesenteric 46% 17% 0.03 Peritonitis 2.4% 0
hematoma blush Localized collection 0 8%
Ileus 1.2% 0
MOI, mechanism of injury; MVC, motor vehicle crash; GCS, Abdominal compartment 1.2% 0
Glasgow Coma Scale; ISS, Injury Severity Score; AIS, Abbre- syndrome
viated Injury Score; OR, operating room; FAST, Focused As- Pancreatic leak 0 4%
sessment Sonography for Trauma; CT, computed tomography.

in Group A (32 vs 4%; P 4 0.005) compared with
Group B. The overall rate of complications was not
statistically significant between the two groups (25 vs
40%; P 4 0.39); however, complications such as
wound infection and localized intra-abdominal col-
lection were more common in the Group B patients.
Other complications such as wound dehiscence, anas-
tomotic leak, peritonitis, and abdominal compartment
syndrome were more frequent in Group A (Table 3),
although it did not reach statistical significance.
Causes of mortality based on postinjury duration
(i.e., less than 24 hours and greater than 24 hours)
showed that nine patients died in first 24 hours (either
on table arrest or a few hours postoperation). All early
mortalities were directly related to magnitude of the
associated injuries irrespective of bowl injury. In
contrast, mortalities after 24 hours of admission were
mostly related to the complications of bowel injuries
(peritonitis, fistula, and sepsis and multiorgan failure).
Using univariate analysis, systolic blood pressure, base
deficit, ISS, and associated pelvic injury were found to
be the major predictors of mortality. However, only
base deficit and ISS were significantly associated with
mortality by multivariate analysis (Table 4).
Figure 1AC shows the overall mortality rate
according to the postinjury time of intervention in-
cluding all patients then after excluding patients who
died within the first 24 hours. Also, the figure shows
the overall mortality in patients who had isolated ab-
dominal injury versus polytrauma.
Discussion
To the best of our knowledge, this is the first report
from our region that describes the diagnosis, predictors,
and outcomes among patients who sustained blunt
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No. 9 TRAUMATIC BOWEL INJURY ? Al-Hassani et al. 925

TABLE 4. Predictors of Mortality

Univariate Analysis Multivariate Analysis
OR (95% CI) P Value OR (95% CI) P Value
Time to OR 0.81 (0.641.03) 0.08 0.91 (0.761.09) 0.29
Blood pressure 0.97 (0.950.99) 0.002 1.04 (0.991.08) 0.08
Base deficit 0.73 (0.630.97) 0.001 0.72 (0.560.92) 0.008
ISS 1.2 (1.111.29) 0.001 1.2 (1.041.29) 0.006
Pelvic injury 3.4 (1.1610.03) 0.03 0.81 (0.115.85) 0.83
Solid organ injury 3.6 (1.2410.79) 0.02 1.12 (0.177.22) 0.91
OR, odds ratio; CI, confidence interval; OR, operating room; ISS, Injury Severity Score.

FIG. 1. (A) Overall mortality according to time of postinjury intervention. (B) Mortality according to time of intervention after
excluding patients who died within the first 24 hours. (C) Overall mortality in patients with isolated abdominal injury versus polytrauma.

bowel injuries. Worldwide, BBMI is rare and the rate
of occurrence is approximately 1 per cent.1, 15, 16 The
current study demonstrates a BBMI incidence rate
of 1.7 per cent for all the trauma admissions and 11
per cent of all the BAT admissions.
Our study shows a higher frequency of pain in the
delayed group (greater than 8 hours) compared with
Group A (less than 8 hours), in which pain sensation
may be less as a result of lower Glasgow Coma Scale
score and higher ISS. This finding is consistent with
previous reports.3, 1418 Delayed diagnosis and surgi-
cal intervention for bowel injury is frequent and re-
mains a diagnostic challenge for clinicians. In addition,
physical examination is often compromised in patients
with multiple injuries.3, 1418
Seatbelt sign has been defined as an area of ecchy-
mosis, erythema, or abrasions sustained secondary to
seatbelt use. In some studies, the presence of a seatbelt
sign is associated with a high risk for intra-abdominal
injury and significant reduction in the time to laparot-
omy once identified.7, 1923 Other studies, however, did
not show the same association.24 Our data show that
seatbelt sign was even significantly higher in the delayed
group (62 vs 26%, P 4 0.02).
The most common CT scan findings in our patients
were the presence of free fluid in both groups and
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926 THE AMERICAN SURGEON
mesenteric hematoma with or without active blush
in the early group (less than 8 hours). Multiple retro-
spective studies have suggested that a finding of free
fluid with or without SOI is a marker for surgical ab-
normality in the abdomen. Some reports have even
demonstrated that lack of those findings is a reliable
indication of the absence of operable intra-abdominal
injuries.8, 25, 26 On the other hand, these findings were
challenged in a large multi-institutional study in which
13 per cent of patients with documented traumatic
small bowel perforation had normal abdominal CT
scans preoperatively.7
Patients who underwent earlier laparotomy (less
than 8 hours) when compared with Group B were
found to have higher ISS, lower blood pressure, hy-
pothermia, and a higher base deficit. Multivariate
logistic regression analysis showed that the mean ISS
and base deficit were the independent predictors of
mortality (Table 4). The higher mortality in those
patients (19.3 vs 4%) could be explained by hemo-
dynamic instability and presence of multiple associ-
ated injuries (Fig. 1). This finding is consistent with
a multi-institutional study conducted by the Eastern
Association for the Surgery of Trauma that showed
that patients who were operated on within the first 24
hours had a higher mortality rate in comparison to
those who were operated on after 24 hours (16.2 vs
15.1%).16
In comparison to data from Fakhry et al.,2 our BBMI
morbidity and mortality rates in polytrauma patients
were higher (15.6 vs 10.6% and 14 vs 12%, respec-
tively), whereas our isolated bowel injury mortality
rate was lower (6 vs 9.2%). Notably, the mortality rate
in the current study dropped from 15.6 to 8 per cent
when those who died within the first 24 hours were
excluded because not all early deaths were related to
bowel injuries. With respect to time to operation of
less than 8 hours, the mortality rate in our series was
almost similar to the Fakhry et al. series (9.7 vs 8.3%);
however, operative delay greater than 8 hours was as-
sociated with less mortality in our series (4 vs 7.8%). It
is also interesting to note that all deaths with isolated
abdominal injuries were in the early group, whereas
in the Fakhry et al. series, all deaths occurred in the
delayed group regardless of the presence of isolated
bowel injury or polytrauma.
The current study did show higher rate of wound
infection and intra-abdominal collection in patients
with surgery delayed for more than 8 hours, yet it is not
statistically significant (Table 3).
There are several limitations of this study. The study
was retrospective in nature; the total number of pa-
tients included was relatively small. In addition, the
real cause of death was not exactly known because no
postmortem studies were done. Economic outcome
September 2013 Vol. 79
like LOS was not addressed in this study. Moreover,
we have to emphasize that all estimates in this study
likely represent the minimum extent of the presence
of BBMI and therefore the true prevalence may be
underestimated. Large prospective studies are needed
to support our findings.
Conclusion
In patients with BAT, several variables are found to
help in the early diagnosis of BBMI such as abdominal
pain, hypotension, ISS, hypothermia, pelvic fracture,
and mesenteric hematoma. ISS and base deficit are
independent predictors of mortality. Delayed operative
interventions more than 8 hours increases morbidity
rate among patients with BBMI but had no significant
impact on mortality.
Acknowledgments
We thank all the staff in the section of Trauma surgery at
Hamad General Hospital for their invaluable cooperation.
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