middle colic artery, trauma
Delayed Rupture of the Middle Colic Artery Secondary to Blunt Abdominal Trauma
From the Department of Emergency Medicine, Meriter Hospitals, Madison, Wisconsin. Received for publication November 8, 1990. Revision received April 18, 1991. Accepted for publication May 2, 1991.
Thomas J Ferrella, MD
The case of a 46-year-old man complaining of acute abdominal discomfort is presented. The patient fell 3 ft and injured his abdomen in the right upper quadrant four days before his emergency department visit. The complete workup revealed an acutely ruptured middle colic artery. The presenting symptoms, laboratory work, differential diagnosis, computed tomography scan, treatment, and follow-up are reviewed. This case is unusual in that delayed rupture of the middle colic artery secondary to blunt abdominal trauma had not been described previously. [Ferrella TJ: Delayed rupture of the middle colic artery secondary to blunt abdominal trauma. Ann EmergMedApri11992;2!:428-430.] INTRODUCTION Acute surgical abdomen secondary to blunt trauma is well described. When b l u n t trauma is the cause of an acute surgical abdomen, the spleen, kidneys, liver, and intestines have a frequency of i n j u r y of more than 82%. 1 The mesenteric arteries, however, are infrequently injured, and to date, delayed r u p t u r e of a mesenteric artery has not been described.2 6 The presentation mimics the other causes of acute surgical abdomen. The definitive diagnosis and treatment are surgical.
A 46-year-old man drove himself to the emergency department with a chief complaint of acute periumbilical abdominal pain beginning 30 minutes before and continuing to admission. The onset of the pain was associated with a normal bowel movement. The patient denied any history of anorexia, nausea, vomiting, diarrhea, syncope, shoulder pain, and respiratory and genitourinary symptoms. He ate lunch without difficulty two hours before admission. He fell 3 ft onto the end of a fixed piece of 2 x 6 in. lumber four days before admission, injuring the right anterolateral subcostal area. Shortness of breath and pain were noted at that time, but he sought no medical attention. Both of these symptoms resolved without incident. The patient had a history of hypertension that was well controlled with captopril. He denied any allergies. He took one aspirin daily. There was no alcohol involved at the time of i n j u r y or the ED admission. •
ANNALS OF EMERGENCY MEDICINE 21:4 APRIL1992
ARTERY RUPTURE FerreUa
There was no history of previous abdominal surgery or medical problems and no family history of vascular disease. Physical examination revealed an uncomfortable, illappearing, alert, oriented, well-developed man. Blood pressure was 150/110 mm Hg; pulse, 56; respirations, 16; and 0ral temperature, 37.1 C. There were no orthostatic vital sign changes. The skin was cool, pale, and moist. The lungs were clear. The cardiac examination demonstrated a regular rate and rhythm without a m u r m u r , rub, or gallop. The right subcostal area was significant for a faint blue-yellow 5-cm2 ecchymosis with mild palpable discomfort. The right ribs were intact and nontender to palpation. The abdomen was diffusely tender with hypoactive bowel sounds and dullness to percussion. No guarding, rebound, or masses were appreciated. Rectal examination was normal; the stool was soft and negative for occult blood. All extremities were normal in color and neurovascular function. Diagnostic tests, including CBC count, amylase chemistry 22, prothrombin time, and partial thromboplastin time, were within normal limits. Urinalysis showed five to ten RBCs and an occasional WBC per high-power field. The upright chest radiograph with right rib details was negative. The patient remained stable with a blood pressure of 135/73 mm Hg and a pulse of 81.. He subsequently was transferred for an abdominal computed tomography (CT) scan with a physician in attendance. The CT scan was significant for free intraperitoneal blood. The source of the bleeding was not found. At this time, the patient was typed and cross-matched for eight units of packed RBCs. While the abdominal CT scan was being performed, the patient's abdominal girth increased significantly. His blood pressure dropped to 84 mm Hg systolic and his pulse climbed to 124. This was easily corrected with an IV bolus of 500 mL lactated Ringer's solution. The abdominal examination then showed a quiet abdomen with dullness to percussion, diffuse tenderness, guarding, and rebound. The patient continued to complain of severe periumbilical pain and was transferred directly to the operating room. An exploratory laparotomy demonstrated 3,000 mL of free intraperitoneal blood and a r u p t u r e d middle colic artery. A large hematoma surrounding a small segment of the traverse colon necessitated an 8-cm colectomy and primary anastomosis. The middle colic artery was tied off. Both the liver and spleen were normal. The patient was discharged nine days after surgery. The pathology report revealed an 8-cm-long piece of transverse colon with extensive hemorrhage into the mesentery. The larger blood vessels showed dissection between the arterial media and adventia with a r u p t u r e d middle colic artery. No previous underlying vascular or bowel lesions were detected. One year after surgery, the patient was doing well with no residual complications such as infections, fistulas, or bowel ischemia.
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Acute ruptures of intra-abdominal blood vessels secondary to blunt trauma have been well described but remain rare. 2-6 These are usually reported as single case studies. Penetrating trauma, on the other hand, accounts for the majority of intra-abdominal vascular injuries.S,6 When vascular abdominal injuries secondary to b l u n t trauma are compared with intra-abdominal organ injuries, the injury rate is quite low. Our case is u n u s u a l because the r u p t u r e of the middle colic artery occurred four days after blunt abdominal trauma. This appears to be the first report of a delayed r u p t u r e d middle colic artery secondary to b l u n t abdominal trauma. Because the middle colic artery is a free-floating artery, the mechanism of !njury in this patient is difficult to explain. Two likely theories are that the middle colic artery was pinched between the spine and the piece of wood or that the fall created a shearing i n j u r y to the artery. Both of these theories could explain a weakened arterial media resulting in a subsequent delayed dissection and rupture. In view of this patient's previous injury, delayed hepatic, splenic, and nephric hemorrhages were top priority considerations. It was also necessary to consider any acute etiologies for the periumbilical pain and diaphoresis, such as an infarcted bowel, r u p t u r e d abdominal aortic aneurysm, ruptured hollow viscus, and nephrolithiasis. Frequent abdominal examinations and vital signs offered additional information to monitor any significant changes. This patient's ill appearance, however, dictated our rapid response more so than the history, vital signs, or physical examination. His chief complaint, in retrospect, most likely represented a dissection of the middle colic artery, and we were fortunate that the r u p t u r e actually occurred in the hospital. His daily use of aspirin undoubtedly facilitated the seriousness of the bleed. The CT scan was preferred over diagnostic peritoneal lavage because the patient was stable and would be accompanied by a physician. SUMMARY
An acute surgical abdomen secondary to a 4-day-old b l u n t abdominal trauma is described. This patient, who presented with an acute surgical abdomen, demonstrated an acutely r u p t u r e d middle colic artery. This finding gives acute care physicians another diagnosis to consider when evaluating abdominal pain in a patient with a history of b l u n t trauma. The definitive diagnosis and treatment are surgical. • I~
4 2 9 / 1 17
ARTERY RUPTURE £errella
Address for reprints: Thomas Ferrella, MD, Department of Emergency Medicine,
1. Shires 6T: Trauma, in Schwartz Sl (ed): Principles of Surgery. New York, Mc6raw-Hill Book Co, 1974, p195-252.
Meriter Hospitals, 202 South Park Street, Madison, Wisconsin 53715-1599.
2. Feliciano BV: Abdominal vascular injuries. Surg Clin North Am 1988; 68:741-755. 3. Liu M, Lui WY, Lee CS, et al: Superior mesenteric vein severance from blunt abdominal trauma: Case report. Taiwan I Hsueh Hui Tsa Chih 1989; 88:183-185. 4. Letsou 6V, 6usberg R: Isolated bilateral renal artery thrombosis: An unusual consequence of blunt abdominal trauma--case report. J Trauma 1990;30:509-511. 5. Sirinek KR, Levine BA: Traumatic injury to the proximal superior mesenteric vessels. Surgery 1985;98:831-835. 6. Accolla KB, Feliciano DV, Mattox KL, et al: Management of injuries to the superior rnesenteric artery. J Trauma 1986;26:313-319.
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