|Year : 2013 | Volume
| Issue : 2 | Page : 144-146
Single jejunal blowout perforation following blunt abdominal trauma: Diagnostic dilemma
Sunder Goyal1, Snigdha Goyal2, MK Garg1
1 Department of General and Minimal Invasive Surgery, Bhagat Phool Singh Government Medical College for Women, Khanpur Kalan, Sonepat, Haryana, India
2 Department of Pathology, Post Graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India
|Date of Web Publication||6-Sep-2013|
Department of General and Minimal Invasive Surgery, BPS Government Medical College for Women, Khanpur Kalan, Sonepat, Haryana
Source of Support: None, Conflict of Interest: None
Single isolated jejunal perforation (IJP) due to blunt abdominal trauma is uncommon and most often occurs with road traffic accidents. The diagnosis of traumatic single IJP is challenging as there are minimal clinical features initially. For most favorable results, strict monitoring, a high index of clinical suspicion, and the help of available appropriate diagnostic tools like diagnostic peritoneal lav age (DPL)/focused abdominal sonography for trauma (FAST) are preferable. Here we report a case of IJP following blunt trauma abdomen.
Keywords: Blunt trauma abdomen, diagnostic peritoneal lavage, isolated jejunum perforation
|How to cite this article:|
Goyal S, Goyal S, Garg M K. Single jejunal blowout perforation following blunt abdominal trauma: Diagnostic dilemma. J Mahatma Gandhi Inst Med Sci 2013;18:144-6
|How to cite this URL:|
Goyal S, Goyal S, Garg M K. Single jejunal blowout perforation following blunt abdominal trauma: Diagnostic dilemma. J Mahatma Gandhi Inst Med Sci [serial online] 2013 [cited 2023 Jun 4];18:144-6. Available from: https://www.jmgims.co.in/text.asp?2013/18/2/144/117798
| Introduction|| |
Blunt abdominal trauma (BAT) can injure any or all abdominal organs, but isolated jejunal perforation (IJP) is extremely rare. The vast majority of intestinal perforations following BAT is caused by motor vehicle accidents, but can also result from physical assault by human beings or animals, or fall from height, or injury caused by bicycle handle bar. The first case of intestinal rupture secondary to blunt trauma was reported by Samuel Annan in 1837.  IJP occurs in less than 1% of blunt trauma patients. To our knowledge, ours is the first case of IJP as a result of animal assault.
A sudden increase in intraluminal pressure in a fluid or air-filled bowel loop causes punctate or slit-like perforations (blowout) on the antimesenteric border. Most of the time, these perforations are not surrounded by damaged tissue because perforation occurs due to raised intraluminal pressure and not due to crushing.  In unconscious patients with multiple injuries, the diagnosis of single IJP is a great dilemma. We can miss IJP in BAT cases because these days most of the solid organs injuries in hemodynamic ally stable patients are managed conservatively.  Delay in diagnosis of IJP adds significant morbidity and mortality. , The clinical suspicion and early exploration in the present case led to prompt surgical intervention and a successful outcome.
| Case Report|| |
A 40-year-old man was admitted in emergency department with a history of BAT for the last 1 day. A horse assaulted him on the abdomen near the umbilical region. After that, he developed pain in the abdomen. On examination, the abdomen was tender around the umbilicus. No bruises or other external injuries were noted. Except for pain abdomen and tachycardia, there was no other positive finding. Erect X-ray abdomen [Figure 1] did not show any air under the diaphragm. But as there was history of trauma, pain abdomen, absent bowel sounds, and tachycardia, the patient was monitored closely. Patient was put on intravenous fluids. After 36 h of injury, the abdomen got distended and tense (probably due to delayed perforation). Ultrasound abdomen showed fluid. Fluid was tapped under ultrasound guidance. As it was bilious in nature, diagnosis of viscous injury was made. Urgent laparotomy was done and the abdomen was found to be filled with bilious fluid. There was a single IJP of size 1 cm × 1 cm at antimesenteric border, about 2 feet away from the ligament of Treitz [Figure 2]. Perforation was closed in two layers. Drains were put in and the abdomen was closed after saline wash. Postoperatively, the patient behaved well and was discharged after 10 days.
| Discussion|| |
The abdomen is the third most commonly injured part of the body following trauma. Early recognition of small bowel injury is important in the prevention of morbidity and mortality.  Seventy-five percent of BATs are caused by motor vehicle accidents and the rest by other modes. , Jejunal perforation due to other injuries are: hit by knee, assault by animal (as in our case), and injury with a bicycle handle bar. Single IJP occurs in less than 1% of blunt trauma patients. 
Mechanisms of small bowel disruption with blunt trauma include shearing forces, compression between the abdominal wall and vertebral column, and blowout injury due to a sudden increase in intraluminal pressure of bowel loop.  The incidence of small bowel injury appears to be lower in children than in adults.  For the early diagnosis of IJP, detailed history (mechanism of injury) and frequent clinical examination of the abdomen are extremely useful, particularly in unconscious patients with other associated intra-abdominal solid organ injuries. Continuous abdominal pain (75.6%), tenderness (46.7%), and a bruise across the abdomen inflicted by a seat belt (seat belt sign) are the important clinical signs of small bowel perforation. ,,
These injuries pose a diagnostic dilemma. Clinical signs are usually vague and nonspecific. Abdominal pain is the most frequent symptom, and in 64% of cases, there are no bowel sounds (as in our case). As delayed perforations can occur after abdominal trauma, prolonged observation and repeated examination upto 72 h are mandatory for proper diagnosis, because BAT causes compression necrosis of the wall of gut, and due to high intraluminal pressure, there may be blowout perforation subsequently. It is not necessary that BAT should cause immediate perforation, as in our case.
Only physical examination is not sufficient for the diagnosis, and it was reliable in only 30% of blunt trauma injuries.  In the early hours of injury, less than 50% of the cases show free air, thus limiting the usefulness of erect X-ray chest or abdomen film (as in our case).
Apart from physical examination, there are four methods for diagnosis of bowel perforation: diagnostic peritoneal lavage (DPL), computed tomography (CT) scan, focused abdominal sonography for trauma (FAST), and diagnostic laparoscopy. Sometimes, DPL is more sensitive than CT imaging for diagnosis of isolated jejunal injury in the early hours; however, in many cases, it results in nontherapeutic laparotomy. Several authors have reported that DPL is an important adjunct in cases where isolated jejunal injury is suspected.  In late hours of injury, FAST and CT are better than DPL. FAST is readily available, reliable, repeatable, and radiation-free diagnostic tool. No doubt, CT scan is the gold standard for assessment of blunt trauma, with a sensitivity of 92%, specificity of 94%, positive predictive accuracy of 30%, negative predictive accuracy of 100%, and overall accuracy (validity) of 94%,  but has got limited role in the early hours of injury and in hemodynamically unstable patients.
The role of laparoscopy in BAT is diagnostic as well as therapeutic in hemodynamically stable patients. Early diagnosis and timely surgical intervention offer the best prognosis.
Open surgical repair or laparoscopic repair is the first line of treatment. Septic peritoneal collection is drained and saline lavage is done. Simple two-layer closure is usually adequate for single perforation of the small intestine (as done in our case).
Although the impact of operative delays on morbidity and mortality has been unclear, a brief delays as little as 8 h can result in increased morbidity and mortality in "missed" small bowel injury.  If small bowel perforation is treated earlier than 12 h, then the rate of complication and mortality is low. Vigilant observation, serial physical examinations, and serial abdominal ultrasound will help in the early diagnosis of obscure single IJP in BAT. 
| Conclusion|| |
The diagnosis of traumatic single IJP is challenging. For most favorable results, strict monitoring, a high index of clinical suspicion and the help of available appropriate diagnostic tools like DPL/FAST are mandatory.
| References|| |
|1.||Chiang WK. Isolated jejunal perforation from nonpenetrating abdominal trauma. Am J Emerg Med 1993;11:473-5. |
|2.||Robbs JV, Moore SW, Pillay SP. Blunt abdominal trauma with jejunal injury: A review. J Trauma 1980;20:308-11. |
|3.||Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D. 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;48:408-15. |
|4.||Thompson SR, Holland AJ. Perforating small bowel injuries in children: Influence of time to operative operation on outcome. Injury 2005;36:1029-33. |
|5.||Munshi IA, DiRocco JD, Khachi G. Isolated jejunal perforation after blunt thoracoabdominal trauma. J Emerg Med 2006;30:393-5. |
|6.||Allen GS, Moore FA, Cox CS Jr, Wilson JT, Cohn JM, Duke JH. Hollow visceral injury and blunt trauma. J Trauma 1998;45:69-78. |
|7.||Neugebauer H, Wallenboeck E, Hungerford M. Seventy cases of injuries of the small intestine caused by blunt abdominal trauma: A retrospective study from 1970 to 1994. J Trauma 1999;46:116-21. |
[Figure 1], [Figure 2]