SCIENTIFIC LETTER

Isolated Jejunal Perforation after Minor BluntAbdominal 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 emergencydepartment with abdominal pain and vomiting for one dayafter sustaining abdominal trauma. The boy had fallen overwhile running on the street and had landed flat on his abdomenthe previous evening. He had developed sudden abdominalpain and was taken to a local hospital where he was observedovernight, found to have no abnormality and discharged thenext morning. On going home, his abdominal pain worsenedand he was brought to our hospital. On examination, he wasafebrile, pulse rate was 98/min with low volume, respiratoryrate 28/min, blood pressure 80/60 mmHg. The abdomen didnot show any visible marks of trauma, there was generalisedtenderness, guarding and absent bowel sounds. He wasresuscitated with normal saline boluses till he was he-modynamically stable and given intravenous antibiotics.Investigations showed hemoglobin 15.6 g/dL, total leucocytecount 2.2×109/L, platelet count 3.23×109/L, blood urea60 mg/dL, creatinine 0.9 mg/dL, SGOT 74 U/L, SGPT20 U/L, normal electrolytes, blood glucose 82 mg/dL andamylase 225 U/L (normal range 28–100). The upright abdom-inal X-ray did not reveal free air under diaphragm. Ultrasoundabdomen revealed free fluid in the peritoneal cavity. OnContrast Enhanced Computed Tomography (CECT) of theabdomen, there was pneumoperitoneum with free fluid(Fig. 1). Exploratory laparotomy demonstrated a solitary6 cm long full thickness jejunal tear, 2 ft distal to theduodeno-jejunal flexure on the antimesentric border. Theedges were freshened and sutured. He was discharged un-eventfully from the hospital on the tenth day.

Intestinal perforation after blunt abdominal trauma (BAT) is arare event and mostly reported with motor vehicle accidents[1]. Other causes are a hard blow to the abdomen, falls fromheight or falls onto an object extending out in 1 direction(clothsline, fence, table, saddle of bike, etc .) [1, 2]. Our caserepresents “blowout” injury of the distended air-filled jejunumthat occurred due to sudden fall on the abdomen. Isolated ilealperforation due to a fall while running has been previouslyreported in an elderly woman [3].

BAT involving solid organs is managed non-operatively inhemodynamically stable patients whereas intestinal perfora-tion requires early surgical intervention to prevent complica-tions resulting from peritonitis, sepsis and multisystem organfailure. In children presenting with BAT, the initial clinical andplain X-ray evidence may often not be suggestive of perfora-tion of hollow viscus [4]. The characteristic pain due toperitonitis resulting from contamination of the peritoneumwith the intestinal contents takes time to develop in smallbowel injury. This is especially so for jejunal perforationsas the contents are neutral with low bacterial load. Beforerelegating this group to non-operative management, anabdominopelvic CECT scan should be considered. The

Fig. 1 Contrast enhanced CT of the abdomen at the level of the liver,showing pneumoperitoneum and free fluid

M. Pandey : R. Sharma (*) :V. KumarDepartment of Pediatrics, Lady Hardinge Medical College andassociated Kalawati Saran Children’s Hospital, Bangla Sahib Road,New Delhi 110001, Indiae-mail: drrajnisharma@yahoo.com

S. Agarwala :R. ChadhaDepartment of Pediatric Surgery, Lady Hardinge Medical Collegeand associated Kalawati Saran Children’s Hospital, New Delhi, India

Indian J PediatrDOI 10.1007/s12098-013-1289-z

presence of pneumoperitoneum on CECT abdomen con-firmed bowel perforation in our case. However, CT scanis known to have high false negative rate for bowel perforationespecially if done in the first few hours after trauma [5]. Inconclusion, the diagnosis of intestinal perforation afterBAT can be challenging for the emergency care physi-cian and mandates a sufficient period of observation, serialphysical examination and additional diagnostic tests asdeemed 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 diagnosinggastrointestinal injury after blunt abdominal trauma in children. CanJ Surg. 1985;28:138–40.

2. Moss RL, Musemeche CA. Clinical judgment is superior to diagnostictests 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 perfo-ration after minor blunt abdominal injury. Eur J Surg. 1995;161:57–8.

4. Schenk WG, Lonchyna V, Moylan JA. Perforation of the jejunumfrom blunt abdominal trauma. J Trauma. 1983;23:54–6.

5. Fakhry SM,Watts DD, Luchette FA. EASTMulti-Institutional HollowViscus Injury Research Group. Current diagnostic approaches lacksensitivity in the diagnosis of perforated blunt small bowel injury:Analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma. 2003;54:295–306.

Indian J Pediatr