Mesenteric Hematoma as a Warning Sign for Missed Bowel Injury

Background Mesenteric hematoma (MH) after blunt abdominal trauma may obscure underlying bowel injury, creating a diagnostic gray zone. We evaluated whether MH identifies patients at higher risk for delayed bowel injury and worse outcomes, informing risk-stratified observation. Methods Adult blunt trauma patients (≥18 years) admitted between January 2018 and August 2025 with MH on initial CT imaging of the abdomen and pelvis and no definitive bowel perforation were retrospectively reviewed (n = 56). Patients were matched 1:1 with trauma patients without MH or bowel injury (N-MH, n = 56) by age, sex, injury mechanism, Injury Severity Score (ISS), and abdominal Abbreviated Injury Scale (AIS). Outcomes, imaging findings, and admission lactic acid were analyzed. Conditional logistic regression identified factors associated with missed bowel injury within 24 h. Results Fifty-six patients with mesenteric hematoma and no definitive CT evidence of bowel perforation were identified. Patients with mesenteric hematoma demonstrated higher admission lactate levels compared with controls. Delayed bowel injury was diagnosed in 7 patients (12.5%) within the first 24 h of hospitalization despite initially inconclusive imaging. Admission lactic acid was independently associated with missed bowel injury (OR 1.10 per mmol/L; 95% CI: 1.01-1.21; P = 0.02). Conclusions Mesenteric hematoma on CT imaging may identify a subgroup of trauma patients at increased risk for delayed bowel injury. These findings suggest that patients with mesenteric hematoma may benefit from heightened surveillance, including serial clinical examinations, physiologic monitoring, and consideration of repeating imaging during the early post-injury period.