Eur J Trauma Emerg Surg DOI 10.1007/s00068-015-0514-z


Blunt abdominal trauma and mesenteric avulsion: a systematic review A. Kordzadeh1 · V. Melchionda1 · K. M. Rhodes2 · E. O. Fletcher1 · Y. P. Panayiotopolous1 

Received: 27 January 2015 / Accepted: 3 March 2015 © Springer-Verlag Berlin Heidelberg 2015

Abstract  Purpose  The aim of this study is to establish the biomechanics, presentation and diagnosis of mesenteric avulsions following blunt abdominal trauma and reach a consensus on their overall management. Materials and methods  A systematic review of literature in MedLine, Embase, Scopus and CINHAL in English language from 1951 to November 2014 was performed. A total of 20 reported cases were identified. Variables including patient’s demographics, signs and symptoms, mechanism of injury, investigative modality, management, length of stay, follow-up and outcomes were reviewed and analyzed. Results  The median age of the cohort was 28.5 years (range 10–58 years), with a male-to-female ratio of 3:1. The commonest mechanism of injury was road traffic accident due to seat belt restraint (n  = 12, 60 %). The commonest presentation was diffuse abdominal tenderness (n = 10, 45 %) followed by ecchymosis/bruising (n = 9, 40 %). Computed tomography (CT) remained the investigative modality of choice (n  = 9, 45 %). All cases had an emergency exploratory laparotomy (n  = 18, 90 %) within the initial 24 h and the median length of stay was 19 days (range 4–90 days). The overall mortality was 15 % (n = 3).

* A. Kordzadeh [email protected] 1

Mid Essex Hospital Services NHS Trust, Department of General and Vascular Surgery, Broomfield Hospital, Court Road, Essex CM1 7ET, UK


Department of Accident and Emergency, Southend University Hospital NHS Foundation Trust, Westcliff‑on‑sea, Essex SS0 0RY, UK

Conclusion  Mesenteric avulsion is rare and has a complex and vague presentation. Due to its potential mortality and morbidity, emergency physicians should keep a high index of suspicion in individuals with blunt abdominal trauma from any mechanism of injury. Keywords  Mesenteric avulsion · Mesenteric laceration · Mesenteric tear · Blunt abdominal Trauma · Seat belt syndrome · Systematic review

Introduction Mesenteric avulsion (MA) following blunt abdominal trauma is rare and occurs in 1–5 % of all cases [1]. Murless in [2], was the first physician to suggest the possibility of a mesenteric avulsion as the result of a nonpenetrating injury. Such injuries are the consequence of high-energy impact and sudden deceleration [3]. Initially, fall from height and compression (crushing) were the commonest etiology behind blunt abdominal trauma. However, due to alterations in health and safety regulations, it appears that seat belt (restraint) and handle bar injury (bicycle) have become the commonest etiology in recent years [4]. Due to their rare nature, complexity in their presentation and diagnosis, emergency physicians should consider mesenteric avulsion in all blunt abdominal traumas. This would assist in targeted management and reduce the incidence of morbidity and mortality. Currently, there is no consensus on their management. Therefore, the objective of this study is to establish the biomechanics, presentation and diagnosis of mesenteric avulsions from blunt abdominal trauma and reach a consensus on their management.


A. Kordzadeh et al.

Materials and methods An electronic search of MedLine, Embase, Scopus and CINHAL for any literature in English language from 1951 to November 2014 was performed. The mesh terms included mesentery or mesenteric and/or avulsion and/or laceration and/or tear. This search produced a total of 168 articles. All abstracts were retrieved and reviewed. The references were also reviewed for any additional cases. An inclusion criterion was limited to any reported cases or reviews on traumatic blunt abdominal injury resulting in mesenteric avulsion, tear and/or laceration. Application of these restrictions revealed a total of 15 articles with 20 cases dating back to 1954. In this review we included patients’ demographics, signs and symptoms, mechanism of trauma, presentation, associated injuries, diagnostic modality, management, outcome and follow up (Table 1).

Results The median age of the cohort was 28.5 years (range 10–58 years), with male predominance (female n = 5, 25 % vs. male n = 15, 75 %) and a male-to-female ratio of 3:1. The commonest mechanism of injury was road traffic accident (RTA) due to seat belt restraint (n  = 12, 60 %), followed by fall from height (n = 4, 20 %), handle bar injury (bicycle) (n = 2, 10 %) and physical violence (n = 2, 10 %) (Fig.  1). The investigative modality of choice was computed tomography (CT) with or without contrast in majority of cases (n = 9, 45 %) followed by ultrasound abdomen (USS) (n = 4, 20 %) and plane radiography (trauma X-ray series prior to availability of CT) (n = 4, 20 %) which was accompanied by diagnostic peritoneal lavage. Two patients were diagnosed with MA at autopsy. Presentation Abdominal tenderness (local & diffuse) and peritonitis was the commonest presentation amongst the entire cohort (n = 12, 60 %). This was associated with abdominal bruising/abrasion and ecchymosis (n = 9, 45 %). Three patients presented with signs of bruising/abrasion and ecchymosis alone. Only five patients (n  = 5, 25 %) showed signs of hemodynamic instability and shock. Three individuals had traumatic abdominal wall hernia (TAWH) (n = 3, 15 %) and one patient (n = 1, 5 %) had malaena. Management All cases had an emergency exploratory laparotomy ± laparoscopy (n = 18, 90 %, n = 2 autopsy) within the initial


24 h of presentation and of them 15 cases (75 %) had bowel resection (small or large bowel) and vessel ligation for partial or complete bowel and mesentery avulsion. Three cases (n  = 3, 15 %) had a successful repair of mesenteric vessels with no bowel resection. Three individuals required traumatic abdominal wall hernia (TAWH) repair along with bowel resection. The most common associated injury was musculoskeletal (abrasion, superficial hematoma, fracture) in ten individuals (n = 10, 50 %). One patient had an aortic transection (n = 1, 5 %) and another had a aortic dissection (n = 1, 5 %). Organ failure involving two or more than 2 organs was noted in four individuals (25 %) that required intensive care support pre and postoperatively. Outcome The median length of hospital stay was 19 days (range 4–90 days). Total of eight patients (n  = 8, 40 %) had an uneventful follow-up, where as 10 cases did not have a clear documentation and one patient required further intervention (n = 1, 5 %). The mortality on presentation to the emergency department was 10 % (n = 2) and overall mortality was 15 % (n = 3).

Discussion The mesentery is a 15–18 cm fan-shaped, two-fold membranous (peritoneal) structure attached to the posterior abdominal wall. It contains blood vessels, lymphatic and nerves that supply the jejunum and the Ileum. Upon its avulsion, patients can loose significant circulatory volume. The compromised blood supply could lead to intestinal ischemia and perforation with significant morbidity and mortality [5]. The clinical presentation may be subtle [6] and according to the current review only 25 % of cases may present with shock and/or hemodynamic instability. The current review shows individuals may only present with vague signs and symptoms of bruising, abrasions and malaena, which could prove challenging for an accurate diagnosis. In fact 58 % of MA following blunt abdominal trauma could be missed on the initial assessment and workup [7]. Biomechanics The literature suggests tearing, shearing, compression and a sudden rise in the intra-abdominal pressure following deceleration to be the main reason behind MA in blunt abdominal traumas [8]. The pathophysiology is complex and depends on the amplitude of deceleration, the mobility (physiological) of the organ and the strength of its attachment [9]. Bege et al. biomechanical analysis of the


Female/23 Male/21 Male/45 Male/26 Male/40 Male/56 Male/54 Male/56 Female/18 Male/21 Male/18 Female/10 Male/31 Male/43 Male/14 Male/15 Male/32 Male/16


Hinckley et al. [17]

Doersch et al. [1] Doersch et al. [18] Doersch et al. [18] Garfinkle et al. [19] Eriksson et al. [20] Eriksson et al. [20] Voiglio et al. [21] Voiglio et al. [21] Pennington et al. [22] Voellinger et al. [23] Marti M et al. [24] Slobogean et al. [25] Woo K et al. [26] Sall I et al. [27] Tonsi et al. [28] Nosanov et al. [29] Yilmaz et al. [30] Yilmaz et al. [30]

Kordzadeh et al. [7]


RTA RTA RTA RTA Physical violence Physical violence Fall Fall RTA RTA Fall RTA RTA RTA Handle bar injury (bicycle) Handle bar injury (bicycle) RTA RTA



Trauma CT

Trauma X-ray abdominal lavage Trauma X-ray abdominal lavage Trauma X-ray abdominal lavage Trauma X-rays Mortality Mortality USS USS Trauma CT Trauma CT Trauma CT Trauma CT Trauma CT Trauma CT Trauma CT Trauma CT USS USS

Trauma X-rays

Investigative modality

RTA road traffic accident (seat belt restrain), TAWH traumatic abdominal wall hernia



Table 1  The patient demographics and clinical characteristics

Exploratory laparotomy

Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Autopsy Autopsy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy Exploratory laparotomy

Exploratory laparotomy



7 Not mentioned Not mentioned 45 – – Not mentioned 30 35 29 19 90 4 20 Not mentioned 7 7 8

Not mentioned

Hospital stay (days)



Associated aortic transection Associated aortic dissection Associated chance fracture

Mesenteric avulsion/bleed Mesenteric avulsion/bleed

Patient died on follow up (sepsis)


Blunt abdominal trauma and mesenteric avulsion


A. Kordzadeh et al.

Fig. 2  Mortality form the time of diagnosis to intervention in mesenteric avulsions Fig. 1  The mechanism of injury

MA revealed that momentum or speed resulting in deceleration does not necessarily determine the severity of the avulsion or its outcome. It is actually the degree of elongation of the mesentery from its anatomical attachment that causes MA [9]. This process can be seen in the “Seat Belt Syndrome” first coined by Aiken in 1963 where seat belt restraint increases the frequency of MA by a factor of 2.1 [10, 11]. This could also explain why low-energy insults such as handle bar and physical violence could also result in mesenteric avulsions. Management An epidemiological study carried out in a regional trauma unit of Canada demonstrated that RTA patients despite their initial stable observation are more likely to have positive exploratory laparotomy than any other mechanism of injury [12]. In addition, the current review shows patients (n = 10, 50 %) to have an associated injury or an inconclusive presentation. Therefore, assessment of individuals according to Advanced Trauma Life Support (ATLS) is clinically important and is highly advocated. Investigation The investigative modality of choice was computed tomography scan (CT) (with or without contrast) and in three cases, a focused assessment with sonography for trauma (FAST) was performed. Currently, The trauma series (CT scan) remains the investigative modality of choice (sensitivity 45 %, specificity 95 % for MA) and should be performed in all individuals following blunt abdominal trauma in the early hours of presentation [13]. In addition, a negative CT (positive in 74 % only) scan does not rule out the requirement for vigilant monitoring, a period of observation and reassessment [14]. In such scenarios, serial blood gas measurement could prove beneficial in the detection of late setting ischemia and/or compensating circulatory loss.


Another modality of investigation for detection of hemoperitoneum and intra-abdominal fluid (sensitivity 52 %) is FAST, [15] but this modality is operator dependent and should be used as a bridging tool rather than a solitary method of investigation. Treatment A partial or a full mesenteric avulsion prompts an immediate surgical (within 24 h) intervention (laparotomy or laparoscopy). This permits a full assessment of the pathology and can lead to an appropriate surgical management (a partial resection or full resection). In recent years there have been reports (n = 3) on successful repair of the mesenteric vessels without bowel resection [16]. In near or total avulsion of the mesentery, the incidences of mortality escalate from the time of presentation to intervention and are presented in Fig. 2 of this manuscript [8]. Following surgery, the risk of further bowel ischemia due to compromised blood supply remains high and an observation period is highly recommended. Overall, the lack of gross clinical and radiological signs in the presence of traumatic abdominal wall hernia (TAWH) (n  = 3, 15 %) should also encourage early surgical intervention as the possibility of subtle mesenteric avulsion or tear remains relatively high.

Conclusion The current review highlights that mesenteric avulsions are more likely to occur secondary to seat belt restraint and are not directly related to the speed or the momentum of the RTA. Their presentation can be vague and non-specific and CT scan should be performed in the early period of admission. The early lack of hemodynamic instability does not rule out the possibility of mesenteric avulsion or tear and the patient may need to be subjected to a period of observation. Upon diagnosis prompt surgical referral could avoid significant mortality and morbidity.

Blunt abdominal trauma and mesenteric avulsion Acknowledgments  No funding was received. Conflict of interest  Ali Kordzadeh, Veronica Melchionda, Karen M.Rhodes, Edward O. Fletcher and Yiannis P. Panayiotopolous declare that they have no conflict of interest. Ethical approval  Not applicable. Human and animal studies  The study described in this article does not contain studies with human or animal subjects performed by any of the authors.

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14. Sharma OP, Oswanski MF, Singer D, et al. The role of computed tomography in diagnosis of blunt intestinal and mesenteric trauma (BIMT). J Emerg Med. 2004;27(1):55–67. 15. Camacho, M. Bowel and Mesenteric Injury. Conf. State of the Art Emergency & Trauma Radiology. American Roengten Ray Society. Washington D.C., 13-18 Apr. 2008. 16. Pennington CJ, Gwaltney N, Sweizer D. Microvascular repair of jejunal and ileal vessels for near complete mesenteric avulsion after seat belt injury. J Trauma. 2000;48:327–9. 17. Hinckley HM, Albertson HA. Avulsion of mesentery with gangrene segment of small bowel (Ileum) following non penetrating trauma of abdomen. Ann Surg. 1954;140(2):257–9. 18. Doersch KB, Dozier WE. The seat belt syndrome. The seat belt sign, intestinal and mesenteric injuries. Am J Surg. 1968;116(6):831–3. 19. Garfinkle SE, Matolo NM. Gastric necrosis from blunt abdominal trauma. J Trauma. 1976;16(5):405–7. 20. Eriksson A. Homicidal blunt abdominal trauma with iso lated laceration of small bowel mesentery. Z Rechtsmed. 1984;93(2):143–6. 21. Voiglio EJ, Boutillier du Retail C, Neidhardt JP, et al. Gastrocolic vein. Definition and report of two cases of avulsion. Surg Radiol Anat. 1998;20(3):197–201. 22. Pennington CJ, Gwaltney N, Sweitzer D. Microvascular repair of jejunal and ileal vessels for near complete mesenteric avulsion after seat belt injury. J Trauma. 2000;48(2):327–9. 23. Voellinger DC, Saddakni S, Melton SM, et al. Endovascular repair of a traumatic infrarenal aortic transection: a case report and review. Vasc Surg. 2001;35(5):385–9. 24. Marti M, Pinilla I, Baudraxler F, Simon MJ, et al. A case of acute abdominal aortic dissection caused b y blunt trauma. Emerg Radiol. 2006;12(4):182–5. 25. Slobogean GP, Tredwell SJ, Masterson JS. Ureteropelvic junction disruption and distal ureter injury associated with a chance fracture following a traffic accident: a case report. I Ortho Surg. 2007;15(2):248–50. 26. Woo K, Margulies DR, Gaon MD, et al. Intracorporeal laparoscopic Management of mesenteric avulsion in a blunt trauma patient. J Truama. 2009;76(4):E104–7. 27. Sall I, El Kaoui H, Bouchentouf SM, et al. Delayed repair for traumatic abdominal wall hernia: is it safe? Hernia. 2009;13(4):447–9. 28. Tonsi AF, Alkusheh M, Reddy K, et al. Bicycle handlebar hernia with multiple enterotomies: a case report. Acta Chir Belg. 2010;110(2):243–5. 29. Nosanov LB, Barthel ER, Pierce JR. Sigmoid perforation and bucket-handle tear of the mseocolon after bucyle handlebar injury: a case report and review of the literature. J Pediatr Surg. 2011;46(12):E33–5. 30. Yilmaz KB, Akinci M, Kaya O, et al. Emergency surgery due to go-kart injuries: report of two consecutive cases. Ulus Travma Acil Cerrahi Derg. 2012;18(2):458–60.


Blunt abdominal trauma and mesenteric avulsion: a systematic review.

The aim of this study is to establish the biomechanics, presentation and diagnosis of mesenteric avulsions following blunt abdominal trauma and reach ...
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