Delayed Small Bowel Perforation with Findings of Severe Ischemia Following Blunt Abdominal Trauma

Abstract

SummaryBackgroundIsolated small bowel perforation following blunt abdominal trauma (BAT) is an uncommon situation with high morbidity and mortality rates, and delayed small bowel perforation is even rarer. The pathophysiology of this condition is not clear in all cases. To the best of our knowledge, this is the first case report of delayed small bowel perforation following BAT with extensive portomesenteric vein gas.Case ReportA 33-year-old male patient was admitted to the emergency department after a car accident. His initial abdominal CT showed no signs of posstraumatic injury. However, follow-up CT, performed after deterioration in his general condition, showed jejunal dilatation, intestinal intramural gas, portomesenteric vein gas, extensive intraperitoneal gas and intraabdominal free fluid. CT findings and emergent laparotomy findings were both compatible with small bowel ischemia-necrosis and perforation.ConclusionsDelayed small bowel perforation following BAT is thought to occur secondary to mesenteric hematoma formation or mesenteric tear complications. Our patient did not have any mesenteric injury or hematoma on initial abdominal CT. We are not aware of any other case report of delayed small bowel perforation following BAT without signs of intraabdominal injury on initial imaging and extensive portomesenteric vein gas on follow-up imaging. Ischemic bowel necrosis was the main cause of portomesenteric vein gas in our case. Posttraumatic patients should be kept under medical observation and abdominal CT should be preferred for imaging in case of a deterioration in the general condition and laboratory findings or appearance of new abdominal complaints.

Isolated jejunal perforation - hidden danger in blunt abdominal trauma

“…Small bowel injury following BAT is very rare with incidence about 1% [9,10]. Even more rare is significant small bowel trauma with only 0.3% cases with small bowel perforation [3][4][5][6] Abdominal injury known as "seatbelt syndrome" with linear ecchymosis on abdominal wall as a result of car accident was described by Garrett and Braunstein in 1962. Simpler form of injury the "seatbelt sing" is expanded to the larger "seatbelt complex" which implies the existence of abdominal organs injures, thorax and spine trauma, major vascular structures trauma, ribs and sternum fractures [9,11].…”

“…Mechanisms of small bowel perforation in BAT are clarified and basically it occurs due to the deceleration forces, bowel compression and blowout trauma due to a sudden intraluminal pressure increase in fluid-filled or air-filled bowel loops [7][8][9][10]. Diagnostic delays and unrecognized small bowel lesions in first 24 hours, have a high incidence of 24%, despite routine use of CT [1,2,3]. Timely diagnosis of isolated jejunal injury can be difficult because of nonspecific clinical findings, absence of peritoneal irritation during abdominal palpation and non-radiological signs of injury immediately after trauma.…”

“…Peritoneal Lavage (DPL) and laparoscopy [3][4][5][6][7][8]. Initial clinical examination can be nonspecific during first hours after the BAT.…”

“…Isolated jejunal perforation (IJP) in blunt abdominal trauma (BAT) is severe but extremely rare injury [1]. Although small intestine trauma is the third most common organ injury in BAT, those injuries have a low incidence of 1-5%, with bowel perforation in only 0.3% patients [1][2][3][4]. However, what is important to point out is that missing intestinal injuries have incidences as high as 24% [1][2][3][4].…”

“…This mechanism of injury in the traffic accidents is created due to a strong decelerating force between human body and seatbelt. Furthermore, the intestinal loops can be suddenly pressed between the anterior abdominal wall and the spinal column, which leads to increased pressure in the bowel lumen and perforation [3][4][5][6]. Significant blunt small bowel and mesenteric injuries (SBBMI) requires surgical treatment are: bowel transection, bowel perforation, segment devascularization, active mesenteric hemorrhage, mesenteric injury with hematoma and intestinal ischemia [4][5][6][7][8].…”