Small Bowel Injuries in Children after Blunt Abdominal Trauma

Small bowel perforation and fatal peritonitis following a fall in a 21-month-old child

“…Less common but well-recognised etiological factors include ''miscellaneous blows,'' often occurring at play; many of these incidents are described as ''unusual'' and indeed the injury may initially seem trivial [5,6,10,13,22]. One study [10] found that ''over half of the children … had histories of seemingly inconsequential trauma to the abdomen, such as tripping or being fallen on by playmates.''…”

“…One study [10] found that ''over half of the children … had histories of seemingly inconsequential trauma to the abdomen, such as tripping or being fallen on by playmates.'' It is, however, difficult to be certain that all such cases, particularly in the older literature, represent accidental infliction, as it is not clear how the history was obtained and how rigorously physical abuse had been excluded [10,13,22]. It is not surprising that falls from a height cause bowel perforation [20,23] but low-level falls including falling over while running may have the same effect [21,24].…”

“…There was a fairly rapid clinical deterioration and the diagnosis was only established at necropsy, which highlights the difficulty in diagnosing small bowel injury in children [4,8,22] for which several reasons have been suggested: children seem to have a greater ''physiological reserve''; communication of symptoms may be a problem with younger children; physical signs and symptoms may be subtle and/or delayed in onset [10,22,25,26]. In particular, bruising of the abdominal wall is by no means a universal finding, having been reported in 7.7-62% of blunt abdominal trauma cases [1,2,5,27,28].…”

“…The majority of such cases are due to vehicle-or bicycle-related accidents or assault, therefore, the possibility of physical abuse must be considered [1][2][3][4][5][6][7][8][9]. However, it should be remembered that falls and ''unusual'' incidents occasionally may be responsible [2,6,[9][10][11][12][13].…”

Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children

“…Often, diagnostic delay is secondary to poor communication between the examiner and the pediatric patient, a lack of specific physical findings suggesting an intra-abdominal lesion, or else the lesion is overshadowed by multiple traumatic injuries. A case series by Kakos et al [ 5 ] reported abdominal pain as the only consistent symptom of blunt small bowel trauma, occurring in twenty-five of twenty-six patients. In cases of blunt duodenal trauma, this lack of specific symptomatology is compounded by the anatomy of the duodenum itself, whose predominantly retroperitoneal location may hide an injury that would be obvious otherwise [ 3 , 6 ].…”