CASE REPORT

Jejunal Tackle: A Case Report of Complete Jejunal Transection in Rugby Union William Perry, MBChB, MPH, Jesse Fischer, MBChB, and Christopher Wakeman, MBChB, MMedSci

Abstract: Jejunal perforation as a result of blunt abdominal trauma during sport is particularly rare. We are aware of 6 reported cases of jejunal perforation in sport: 1 in hockey, 2 in football (soccer), and 3 in American football. This report presents the case of a 25-year-old professional rugby union player, who presented to an “After Hours” general practice clinic with increasing central abdominal and epigastric pain after a heavy tackle during an international match in New Zealand. Despite suffering complete jejunal transection, the patient continued to play on, only presenting to an After Hours general practice clinic 3 hours after the injury. The case demonstrates the remarkable physiological resilience of professional rugby players and acts as a reminder to maintain a high degree of suspicion for small bowel injury despite normal vital signs in healthy young patients with abdominal pain secondary to blunt trauma. Key Words: blunt trauma, small bowel injury, rugby union (Clin J Sport Med 2014;24:e54–e55)

INTRODUCTION Jejunal perforation as a result of blunt abdominal trauma during sport is rare. We are aware of 6 reported cases of jejunal perforation in sport.1–4 All were the result of blunt abdominal trauma to an upright athlete and only one of them was of complete transection.3 We present a case of complete jejunal transection resulting from a tackle during a premier level rugby union game.

CASE REPORT A 25-year-old male professional rugby union player presented to an “After Hours” general practice clinic with increasing central abdominal and epigastric pain after a heavy tackle nearly 3 hours earlier during an international match in New Zealand. Immediately after the injury, he continued to play before retiring approximately 10 minutes later. An erect chest x-ray was performed at the clinic, and although no abnormality was detected, he was referred to the emergency department of our tertiary referral hospital because of persistent abdominal pain and tenderness 4 hours after injury. Submitted for publication February 6, 2013; accepted August 1, 2013. From the Department of General Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand. The authors report no conflicts of interest. Corresponding Author: Christopher Wakeman, MBChB, MMedSci, FRACS, Department of General Surgery, Christchurch Hospital, Canterbury District Health Board, Riccarton Ave, Christchurch, 8011, New Zealand ([email protected]). Copyright © 2013 by Lippincott Williams & Wilkins

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On presentation, he appeared well from the end of the bed and was afebrile with a heart rate of 80 bpm, a blood pressure of 130/70 mm Hg, and a respiratory rate of 20 breaths per minute. On examination, he had signs of peritonism with a rigid guarded abdomen. There was a maximal tenderness in the epigastric region and tenderness in the left upper and left lower quadrants. Bowel sounds were absent. Examination of the systems was otherwise unremarkable. Blood results revealed a normal C-reactive protein and full blood count with the exception of mildly elevated neutrophils (7.9 · 109/L). He was found to be in acute renal failure with a creatinine level of 200 mmol/L. Urine analysis was normal with no hematuria present. A focused assessment with sonography for trauma scan in the emergency department showed free fluid in the abdomen, but because he was hemodynamically stable, he was transferred for a computed tomography (CT) scan of the abdomen. The CT scan demonstrated a moderate amount of free intraperitoneal gas and fluid throughout the abdomen and pelvis. There was a thick-walled loop of jejunum with associated stranding in the left upper quadrant, distal to the duodenojejunal (DJ) flexure, with surrounding free fluid and multiple locules of free gas suggestive of local perforation in this region (Figure 1). In retrospect, the initial erect chest x-ray was noted to demonstrate a small amount of free air under the diaphragm. After diagnosis, he was taken to the operating theater and laparotomy was performed. On removing the bowel from the abdomen, it was obvious that the jejunum was completely transected 35 cm from the DJ flexure with an associated mesenteric tear (Figure 2). The injured small bowel was resected, and the free ends were joined with a side-toside stapled anastomosis. The remaining bowel and other abdominal organs were assessed and no additional injury was found. Postoperatively, he was managed in the surgical high-dependency unit. His renal failure was resolved by day 3, and he was discharged on postoperative day 9. Two months after injury, he returned to training and played his first professional match approximately 2 weeks thereafter.

DISCUSSION The incidence of small bowel perforation after blunt abdominal trauma is suggested to be 0.3%,5 with most cases resulting from motor vehicle accidents.5,6 Jejunal perforation, as a result of blunt abdominal trauma during sport, is thus particularly rare. We found 6 reported cases of jejunal perforation in sport: 1 in hockey, 2 in football (soccer), and 3 in American football.1–4 We are not aware of any reported cases of such injury occurring in rugby. Only 1 reported case of perforation involved complete transection.3 Despite suffering a major intra-abdominal injury, the patient continued to play on, only to be seen by our emergency department staff 4 hours after the injury. Late diagnosis of hollow viscous perforation is known to be associated with significant morbidity and mortality.7 When first seen, he was maintaining a pulse and blood pressure in the normal range Clin J Sport Med  Volume 24, Number 5, September 2014

Clin J Sport Med  Volume 24, Number 5, September 2014

Complete Jejunal Transection in Rugby Union

FIGURE 1. Transverse (left) and coronal (right) CT images.

despite a significant time since the injury, although he did present with the classic triad of bowel perforation: abdominal rigidity, marked tenderness, and absent bowel sounds. This case demonstrates the remarkable physiological resilience of professional rugby players and acts as a reminder to maintain a high degree of suspicion for small bowel injury, despite normal vital signs in healthy young patients with abdominal pain secondary to blunt trauma. If this were a more moderate perforation rather than complete transection, his symptoms may have been more subtle still. The diagnosis of such jejunal injuries is often delayed,8–10 despite advanced imaging, with a CT sensitivity of between 69% and 95%.11–13 Serial clinical assessment, with or without serial imaging, is therefore crucial; it is thought that intra-abdominal injury can be excluded if the patient has a return of normal bowel function.14 If there are ongoing symptoms, consideration of early exploratory laparotomy or diagnostic peritoneal lavage is essential, especially if there are nonspecific signs on imaging such as streaky density in the mesentery or free peritoneal fluid.12,13 There is some debate in the literature as to the mechanism of small bowel injuries due to blunt trauma. Three mechanisms are commonly discussed: shearing forces, compression between the abdominal wall and vertebral column, and bursting injury because of a sudden increase in intraluminal pressure.10 Given the nature of the tackle, it is likely that the jejunum was compressed under tension between the tackled abdominal wall and the vertebral column with the ligament of Treitz and the

FIGURE 2. Intraoperative photograph of the transected jejunum as it appeared on being exteriorized from the abdomen.  2013 Lippincott Williams & Wilkins

retroperitoneal portion of the duodenum acting as a point of pivot. Such mechanisms seem to be favored by most authors.10,15,16 This is similar to the mechanism described in duodenal–jejunal injury associated with safety belts in motor vehicle accidents: The duodenum or jejunum is compressed between the safety belt or steering wheel and vertebral column. This is often associated with a chance of fracture of the vertebral column. REFERENCES 1. Baker BE. Jejunal perforation occurring in contact sports. Am J Sports Med.1978;6:403–404. 2. Murphy CP, Drez D. Jejunal rupture in a football player. Am J Sports Med. 1987;15:184–185. 3. Sandiford NA, Sutcliffe RP, Khawaja HT. Jejunal transection after blunt abdominal trauma: a report of two cases. Emerg Med J. 2006;23:e55. 4. Fakhry SM, Watts DD, Luchette FA. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis of 275,557 trauma admissions from the EAST Multi-Institutional HVI Trial. J Trauma. 2003;54:295–306. 5. Dauterive AH, Flancbam L, Cox EF. Blunt intestinal injury: a modern day review. Ann Surg. 1985;201:198–203. 6. Holt RW, Wolf GT, Franco PE. Rupture of the jejunum secondary to blunt trauma in a football player. S Med J. 1976;69:281. 7. Fakhry SM, Brownstein M, Watts DD, et al. Relatively short diagnostic delays (,8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma. 2000;48:408–415. 8. Subramanian V, Raju RS, Vyas FL, et al. Delated jejunal perforation following blunt abdominal trauma. Ann R Coll Surg Engl. 2010;92:W23–24. 9. Sule AZ, Kidmas AT, Awani K, et al. Gastrointestinal perforation following blunt abdominal trauma. East Afr Med J. 2007;84:429–433. 10. Robbs JV, Moore JW, Pillay SP. Blunt abdominal trauma with jejunal injury: a review. J Trauma. 1980;20:308–311. 11. Nghiem HV, Jeffrey RB Jr, Mindelzun RE. CT of blunt trauma to the bowel and mesentry. Semin Ultrasound CT MR. 1995;16:82–90. 12. Hagiwara A, Yukioka T, Satou M, et al. Early diagnosis of small intestine rupture from blunt abdominal trauma using computed tomography: significance of the streaky density within the mesentry. J Trauma. 1995; 38:630–633. 13. Eanniuello VC II, Gabram SG, Eusebio R, et al. Isolated free fluid on abdominal computed tomographic scan: an indication for surgery in blunt trauma patients? Conn Med 1994;58:707–710. 14. Baccoli A, Manconi AR, Caocci G, et al. Isolated jejunal perforation after blunt trauma. Report of three cases. G Chir. 2010;31:167–170. 15. Williams RD, Sargent FT. The mechanism of intestinal injury in trauma. J Trauma 1963:31;735–748. 16. Orloff MJ, Charters AC. Injuries of the small bowel and mesentry and retroperitoneal hematoma. Surg Clin North Am. 1972;52:729.

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Jejunal tackle: a case report of complete jejunal transection in rugby union.

Jejunal perforation as a result of blunt abdominal trauma during sport is particularly rare. We are aware of 6 reported cases of jejunal perforation i...
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