Indian J Pediatr DOI 10.1007/s12098-013-1289-z
SCIENTIFIC LETTER
Isolated Jejunal Perforation after Minor Blunt Abdominal Trauma Meenu Pandey & Rajni Sharma & Surendrakumar Agarwala & Rajiv Chadha & Virendra Kumar
Received: 18 June 2013 / Accepted: 28 October 2013 # Dr. K C Chaudhuri Foundation 2013
To the Editor: A 9-y-old boy presented to our emergency department with abdominal pain and vomiting for one day after sustaining abdominal trauma. The boy had fallen over while running on the street and had landed flat on his abdomen the previous evening. He had developed sudden abdominal pain and was taken to a local hospital where he was observed overnight, found to have no abnormality and discharged the next morning. On going home, his abdominal pain worsened and he was brought to our hospital. On examination, he was afebrile, pulse rate was 98/min with low volume, respiratory rate 28/min, blood pressure 80/60 mmHg. The abdomen did not show any visible marks of trauma, there was generalised tenderness, guarding and absent bowel sounds. He was resuscitated with normal saline boluses till he was hemodynamically stable and given intravenous antibiotics. Investigations showed hemoglobin 15.6 g/dL, total leucocyte count 2.2×109/L, platelet count 3.23×109/L, blood urea 60 mg/dL, creatinine 0.9 mg/dL, SGOT 74 U/L, SGPT 20 U/L, normal electrolytes, blood glucose 82 mg/dL and amylase 225 U/L (normal range 28–100). The upright abdominal X-ray did not reveal free air under diaphragm. Ultrasound abdomen revealed free fluid in the peritoneal cavity. On Contrast Enhanced Computed Tomography (CECT) of the abdomen, there was pneumoperitoneum with free fluid (Fig. 1). Exploratory laparotomy demonstrated a solitary 6 cm long full thickness jejunal tear, 2 ft distal to the duodeno-jejunal flexure on the antimesentric border. The edges were freshened and sutured. He was discharged uneventfully from the hospital on the tenth day.
Intestinal perforation after blunt abdominal trauma (BAT) is a rare event and mostly reported with motor vehicle accidents [1]. Other causes are a hard blow to the abdomen, falls from height or falls onto an object extending out in 1 direction (clothsline, fence, table, saddle of bike, etc.) [1, 2]. Our case represents “blowout” injury of the distended air-filled jejunum that occurred due to sudden fall on the abdomen. Isolated ileal perforation due to a fall while running has been previously reported in an elderly woman [3]. BAT involving solid organs is managed non-operatively in hemodynamically stable patients whereas intestinal perforation requires early surgical intervention to prevent complications resulting from peritonitis, sepsis and multisystem organ failure. In children presenting with BAT, the initial clinical and plain X-ray evidence may often not be suggestive of perforation of hollow viscus [4]. The characteristic pain due to peritonitis resulting from contamination of the peritoneum with the intestinal contents takes time to develop in small bowel injury. This is especially so for jejunal perforations as the contents are neutral with low bacterial load. Before relegating this group to non-operative management, an abdominopelvic CECT scan should be considered. The
M. Pandey : R. Sharma (*) : V. Kumar Department of Pediatrics, Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, Bangla Sahib Road, New Delhi 110001, India e-mail: [email protected] S. Agarwala : R. Chadha Department of Pediatric Surgery, Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, New Delhi, India
Fig. 1 Contrast enhanced CT of the abdomen at the level of the liver, showing pneumoperitoneum and free fluid
Indian J Pediatr
presence of pneumoperitoneum on CECT abdomen confirmed bowel perforation in our case. However, CT scan is known to have high false negative rate for bowel perforation especially if done in the first few hours after trauma [5]. In conclusion, the diagnosis of intestinal perforation after BAT can be challenging for the emergency care physician and mandates a sufficient period of observation, serial physical examination and additional diagnostic tests as deemed necessary. Contribution Dr Virendra Kumar will act as guarantor for this paper. Conflict of Interest None. Role of Funding Source None.
References 1. Mercer S, Legrand L, Stringel G, Soucy P. Delay in diagnosing gastrointestinal injury after blunt abdominal trauma in children. Can J Surg. 1985;28:138–40. 2. Moss RL, Musemeche CA. Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg. 1996;31:1178–81. 3. Bloom AI, Reissman P, Eid A, Durst AL. Isolated ileal perforation after minor blunt abdominal injury. Eur J Surg. 1995;161: 57–8. 4. Schenk WG, Lonchyna V, Moylan JA. Perforation of the jejunum from blunt abdominal trauma. J Trauma. 1983;23:54–6. 5. Fakhry SM, Watts DD, Luchette FA. EAST Multi-Institutional Hollow Viscus Injury Research Group. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: Analysis from 275,557 trauma admissions from the EAST multiinstitutional HVI trial. J Trauma. 2003;54:295–306.
SCIENTIFIC LETTER
Isolated Jejunal Perforation after Minor Blunt Abdominal Trauma Meenu Pandey & Rajni Sharma & Surendrakumar Agarwala & Rajiv Chadha & Virendra Kumar
Received: 18 June 2013 / Accepted: 28 October 2013 # Dr. K C Chaudhuri Foundation 2013
To the Editor: A 9-y-old boy presented to our emergency department with abdominal pain and vomiting for one day after sustaining abdominal trauma. The boy had fallen over while running on the street and had landed flat on his abdomen the previous evening. He had developed sudden abdominal pain and was taken to a local hospital where he was observed overnight, found to have no abnormality and discharged the next morning. On going home, his abdominal pain worsened and he was brought to our hospital. On examination, he was afebrile, pulse rate was 98/min with low volume, respiratory rate 28/min, blood pressure 80/60 mmHg. The abdomen did not show any visible marks of trauma, there was generalised tenderness, guarding and absent bowel sounds. He was resuscitated with normal saline boluses till he was hemodynamically stable and given intravenous antibiotics. Investigations showed hemoglobin 15.6 g/dL, total leucocyte count 2.2×109/L, platelet count 3.23×109/L, blood urea 60 mg/dL, creatinine 0.9 mg/dL, SGOT 74 U/L, SGPT 20 U/L, normal electrolytes, blood glucose 82 mg/dL and amylase 225 U/L (normal range 28–100). The upright abdominal X-ray did not reveal free air under diaphragm. Ultrasound abdomen revealed free fluid in the peritoneal cavity. On Contrast Enhanced Computed Tomography (CECT) of the abdomen, there was pneumoperitoneum with free fluid (Fig. 1). Exploratory laparotomy demonstrated a solitary 6 cm long full thickness jejunal tear, 2 ft distal to the duodeno-jejunal flexure on the antimesentric border. The edges were freshened and sutured. He was discharged uneventfully from the hospital on the tenth day.
Intestinal perforation after blunt abdominal trauma (BAT) is a rare event and mostly reported with motor vehicle accidents [1]. Other causes are a hard blow to the abdomen, falls from height or falls onto an object extending out in 1 direction (clothsline, fence, table, saddle of bike, etc.) [1, 2]. Our case represents “blowout” injury of the distended air-filled jejunum that occurred due to sudden fall on the abdomen. Isolated ileal perforation due to a fall while running has been previously reported in an elderly woman [3]. BAT involving solid organs is managed non-operatively in hemodynamically stable patients whereas intestinal perforation requires early surgical intervention to prevent complications resulting from peritonitis, sepsis and multisystem organ failure. In children presenting with BAT, the initial clinical and plain X-ray evidence may often not be suggestive of perforation of hollow viscus [4]. The characteristic pain due to peritonitis resulting from contamination of the peritoneum with the intestinal contents takes time to develop in small bowel injury. This is especially so for jejunal perforations as the contents are neutral with low bacterial load. Before relegating this group to non-operative management, an abdominopelvic CECT scan should be considered. The
M. Pandey : R. Sharma (*) : V. Kumar Department of Pediatrics, Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, Bangla Sahib Road, New Delhi 110001, India e-mail: [email protected] S. Agarwala : R. Chadha Department of Pediatric Surgery, Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, New Delhi, India
Fig. 1 Contrast enhanced CT of the abdomen at the level of the liver, showing pneumoperitoneum and free fluid
Indian J Pediatr
presence of pneumoperitoneum on CECT abdomen confirmed bowel perforation in our case. However, CT scan is known to have high false negative rate for bowel perforation especially if done in the first few hours after trauma [5]. In conclusion, the diagnosis of intestinal perforation after BAT can be challenging for the emergency care physician and mandates a sufficient period of observation, serial physical examination and additional diagnostic tests as deemed necessary. Contribution Dr Virendra Kumar will act as guarantor for this paper. Conflict of Interest None. Role of Funding Source None.
References 1. Mercer S, Legrand L, Stringel G, Soucy P. Delay in diagnosing gastrointestinal injury after blunt abdominal trauma in children. Can J Surg. 1985;28:138–40. 2. Moss RL, Musemeche CA. Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg. 1996;31:1178–81. 3. Bloom AI, Reissman P, Eid A, Durst AL. Isolated ileal perforation after minor blunt abdominal injury. Eur J Surg. 1995;161: 57–8. 4. Schenk WG, Lonchyna V, Moylan JA. Perforation of the jejunum from blunt abdominal trauma. J Trauma. 1983;23:54–6. 5. Fakhry SM, Watts DD, Luchette FA. EAST Multi-Institutional Hollow Viscus Injury Research Group. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: Analysis from 275,557 trauma admissions from the EAST multiinstitutional HVI trial. J Trauma. 2003;54:295–306.
