Gastrointestinal tract perforation in children due to blunt abdominal trauma

Abstract

Over a 14-year period 587 children under 13 years of age were admitted with blunt injury to the abdomen. Twenty-nine (4.9 per cent) of these were found to have bowel rupture. Evidence of peritonitis was present at initial evaluation in 11 children (38 per cent). Radiological evidence of perforation (pneumoperitoneum) was present in only five of 27 (19 per cent) with a further six of 27 (22 per cent) showing dilated loops of bowel or fluid levels. Thus 59 per cent of radiographs were not diagnostic. The mean time from admission to laparotomy was 17 h. Proximal bowel perforation was common and perforation at multiple sites occurred in five patients; 59 per cent had a concomitant injury which resulted in two deaths (from head injury). Initial clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in significant diagnostic delay. Frequently repeated clinical examination is advocated; progression of abdominal signs should alert the clinician to proceed to laparotomy.

Gastrointestinal injuries from blunt abdominal trauma in children

“…Though one study (5) has noted that GIT injuries occur in <1% of children following blunt abdominal trauma, the rate of GIT perforation is 4.3%-8.5% in most reports (6)(7)(8). In the present study, the rate of GIT perforation following blunt abdominal trauma was 16.3%, but the number of our patients was small.…”

“…CT scan is not readily available in our environment. Other investigations such as diagnostic peritoneal lavage may be useful and elevated serum amylase may be suggestive (6). In one study, (7) elevated transaminases and white blood cell were significantly higher in patients with peritonitis compared to those with minimal or normal findings.…”

“…Of 10 patients in this study, only three had evidence of pneumoperitoneum on plain abdominal radiography and the remaining had non-specific features such as dilated bowel loops and fluid levels. Other studies have noted pneumoperitoneum in 8.5% -46% of patients (6)(7)(8). Computed tomography (CT) scan may be useful in detecting clinically significant intestinal or mesenteric injury (9) and may show specific features of GIT perforation such as free air and localized low density fluid (10).…”

“…Associated intraabdominal and extraabdominal injuries were frequent in these patients. Simple closure is usually adequate for single perforation of the stomach and small intestine (6,7,14) but more extensive injuries such as multiple perforations and gangrene from mesenteric injury may require resection and anastomosis. Large bowel injures, particularly in the left colon may require creation of stoma.…”

An unusual case of handlebar injury

“…Early diagnosis of a perforated small bowel could pose a challenge secondary to neutral pH and low bacterial content of the lumen [17]. Initial radiographs may be normal in up to 60% of cases [18]. Some clues to diagnosis are free fluid on ultrasound, increasing tachycardia and rising white count.…”