# Grade V AAST Intestinal Vascular Injury Secondary to Blunt Abdominal Trauma: A Case Report From a University Hospital in Saltillo, Mexico

## TL;DR

A 65-year-old man with blunt abdominal trauma from a bicycle accident was found to have a severe intestinal injury requiring surgery, highlighting the importance of thorough evaluation in such cases.

## Contribution

This case report presents a rare Grade V AAST intestinal vascular injury caused by blunt trauma and emphasizes the need for careful clinical re-evaluation.

## Key findings

- The patient had a Grade V AAST intestinal injury with a devascularized ileal segment and mesenteric hematoma.
- The injury was initially suspected via the 'string of pearls' sign on imaging and confirmed during surgery.
- The patient recovered well post-surgery and was discharged with no complications.

## Abstract

A 65-year-old male with no relevant medical history presented to the emergency department with generalized abdominal pain following blunt trauma caused by a bicycle handlebar impact to the mesogastrium 48 hours prior. The patient initially self-medicated with analgesics without improvement. Upon evaluation, he had stable vital signs, epigastric ecchymosis, decreased peristalsis, and signs of generalized peritonism. Laboratory results showed leukocytosis (17.6 x 109/L). Plain abdominal radiographs showed intestinal loops with diameters within normal limits and a few short air-fluid levels in the left hypochondrium. Notably, the distribution of intraluminal gas in that region revealed a “string of pearls” sign, raising suspicion for an obstructive process. An abdominal CT scan revealed inflammatory pelvic changes, mesenteric fat stranding, dilated ileal loops, and free fluid in the pelvic cavity. Exploratory laparotomy showed 150 mL of serosanguineous fluid, a mesenteric border hematoma of the ileum 100 cm from the ileocecal valve, a phlegmon with adhesions, and a 12.5 cm devascularized segment of ileum (bucket handle injury) with necrosis located 120 cm from the ileocecal valve, classified as AAST (American Association for the Surgery of Trauma) Grade V injury and signs of acute appendicitis (erythema and fibrinopurulent coating). Resection with end-to-end anastomosis and appendectomy was performed. The patient tolerated oral intake by postoperative day 2 and was discharged with outpatient follow-up. Histopathology confirmed intestinal necrosis with regional peritonitis and periappendicitis. In patients with blunt abdominal trauma, the most frequently affected organs are the spleen, liver, and small intestine. Injuries to these organs can be missed when the trauma mechanism is underestimated; therefore, frequent physical re-evaluation is essential, as a single examination does not completely exclude the presence of injury.