No abstract

A 31-year-old woman sustained multiple injuries, including a degloving scalp wound with extensive bleeding; head injury with subarachnoid and petechial hemorrhage; and fractures of the cervical spine, ribs, clavicle, radius, and metacarpal in a rollover motor vehicle crash. She received 3 L of crystalloid resuscitation during air transport to the medical center 3 hours postinjury. Her systolic blood pressure at admission was 90 mm Hg. Her initial hematocrit, in the trauma bay, was 16%. After receiving 2 more L of crystalloid and four units of blood, her hematocrit was 31%. A spiral computed tomographic (CT) scan of her abdomen was obtained with intravenous contrast 4 hours postinjury and showed diffuse dilation of the small bowel having the appearance of calamari ( Fig. 1). The small-caliber inferior vena cava indicated that intravascular volume was not yet restored.The differential diagnostic considerations for the CT appearance of the small bowel in this clinical setting include (1) small bowel ischemia and edema secondary to resuscitation for prolonged hypovolemic shock in the setting of significant blood loss from the extensive scalp wound and (2) small bowel injury, although that radiographic pattern is typically more focal and eccentric. In the absence of peritoneal signs, we accepted the first diagnosis and managed her abdomen nonoperatively, as her continued resuscitation (norepinephrine in addition to blood and crystalloids) corrected her hemodynamic instability within the next 48 hours.On the third hospital day, she underwent surgical fixation of her fractured cervical spine. A subsequent abdominal CT scan obtained on the fourth hospital day showed that the small bowel had returned to normal, the retroperitoneal and intraperitoneal fluid had decreased, and the inferior vena cava was of normal caliber (Fig. 2). She progressively improved and, after a brief stay in rehabilitation, returned home for outpatient therapy.The "calamari sign" with circumferential wall thickening and increased contrast enhancement of the entire small bowel aids in differentiating diffuse edematous nonnecrotic injury from focal tissue destructive bowel injury that would necessitate operative intervention. These CT findings, which are reversible and which have been reported in children 1 and adults, 2 may aid in selecting a course of nonoperative management. REFERENCES1. Sivit CJ, Taylor GA, Bulas DI, Kushner DC, Potter BM, Eichelberger MR. Posttraumatic shock in children: CT findings associated with hemodynamic instability. Pediatr Radiol. 1992;182:723-726. 2. Mivis SE, Shanmuganathan RE. Diffuse small-bowel ischemia in hypotensive adults after blunt trauma (shock bowel): CT findings and clinical significance. Fig. 1. Computed tomographic scan of the abdomen at admission showing diffuse small bowel dilatation with circumferential wall thickening and increased contrast enhancement having the appearance of calamari, a small-caliber inferior vena cava, and diffuse intraperitoneal and retroperitoneal fluid. Fig. 2. Computed tomograph...