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Case Report

Single jejunal blowout perforation following blunt


abdominal trauma: Diagnostic dilemma
Sunder Goyal, Snigdha Goyal1, M. K. Garg

Abstract
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

Introduction Most of the time, these perforations are not surrounded


by damaged tissue because perforation occurs due to
Blunt abdominal trauma (BAT) can injure any or all raised intraluminal pressure and not due to crushing.
abdominal organs, but isolated jejunal perforation [2]
In unconscious patients with multiple injuries, the
(IJP) is extremely rare. The vast majority of intestinal diagnosis of single IJP is a great dilemma. We can miss
perforations following BAT is caused by motor vehicle IJP in BAT cases because these days most of the solid
accidents, but can also result from physical assault by organs injuries in hemodynamic ally stable patients
human beings or animals, or fall from height, or injury are managed conservatively.[3] Delay in diagnosis
caused by bicycle handle bar. The first case of intestinal of IJP adds significant morbidity and mortality.[3,4]
rupture secondary to blunt trauma was reported by The clinical suspicion and early exploration in the
Samuel Annan in 1837.[1] IJP occurs in less than 1% present case led to prompt surgical intervention and a
of blunt trauma patients. To our knowledge, ours is the successful outcome.
first case of IJP as a result of animal assault.
Case Report
A sudden increase in intraluminal pressure in a fluid
or air-filled bowel loop causes punctate or slit-like A 40-year-old man was admitted in emergency
perforations (blowout) on the antimesenteric border. department with a history of BAT for the last 1 day. A
Access this article online
horse assaulted him on the abdomen near the umbilical
Quick Response Code: region. After that, he developed pain in the abdomen.
Website:
www.jmgims.co.in
On examination, the abdomen was tender around the
umbilicus. No bruises or other external injuries were
noted. Except for pain abdomen and tachycardia, there
DOI:
10.4103/0971-9903.117798 was no other positive finding. Erect X-ray abdomen
[Figure 1] did not show any air under the diaphragm.

Department of General and Minimal Invasive Surgery, Bhagat Phool Singh Government Medical College for Women,
Khanpur Kalan, Sonepat, Haryana, 1Department of Pathology, Post Graduate Institute of Medical Education and Research
and Dr. Ram Manohar Lohia Hospital, New Delhi, India

Address for correspondence:


Dr. Sunder Goyal, Professor and Head, Department of General and Minimal Invasive Surgery, BPS Government Medical
College for Women, Khanpur Kalan, Sonepat, Haryana, India. E-mail: goyal.sunder@yahoo.in

Journal of Mahatma Gandhi Institute of Medical Sciences September 2013 | Vol 18| Issue 2
Goyal, et al.: Single jejunal blowout perforation following blunt abdominal trauma 145

Figure 2: Showing isolated single perforation at antimesenteric


Figure 1: Erect X-ray abdomen without air under diaphragm border

But as there was history of trauma, pain abdomen, patients with other associated intra-abdominal solid
absent bowel sounds, and tachycardia, the patient was organ injuries. Continuous abdominal pain (75.6%),
monitored closely. Patient was put on intravenous tenderness (46.7%), and a bruise across the abdomen
fluids. After 36 h of injury, the abdomen got distended inflicted by a seat belt (seat belt sign) are the important
and tense (probably due to delayed perforation). clinical signs of small bowel perforation.[2,3,7]
Ultrasound abdomen showed fluid. Fluid was tapped
under ultrasound guidance. As it was bilious in nature, These injuries pose a diagnostic dilemma. Clinical
diagnosis of viscous injury was made. Urgent laparotomy signs are usually vague and nonspecific. Abdominal
was done and the abdomen was found to be filled with pain is the most frequent symptom, and in 64% of
bilious fluid. There was a single IJP of size 1 cm × 1 cases, there are no bowel sounds (as in our case). As
cm at antimesenteric border, about 2 feet away from the delayed perforations can occur after abdominal trauma,
ligament of Treitz [Figure 2]. Perforation was closed in prolonged observation and repeated examination upto
two layers. Drains were put in and the abdomen was 72 h are mandatory for proper diagnosis, because
closed after saline wash. Postoperatively, the patient BAT causes compression necrosis of the wall of gut,
behaved well and was discharged after 10 days. and due to high intraluminal pressure, there may be
blowout perforation subsequently. It is not necessary
Discussion that BAT should cause immediate perforation, as in
our case.
The abdomen is the third most commonly injured
part of the body following trauma. Early recognition Only physical examination is not sufficient for the
of small bowel injury is important in the prevention diagnosis, and it was reliable in only 30% of blunt
of morbidity and mortality.[5] Seventy-five percent of trauma injuries.[6] In the early hours of injury, less
BATs are caused by motor vehicle accidents and the than 50% of the cases show free air, thus limiting the
rest by other modes.[3,4] Jejunal perforation due to other usefulness of erect X-ray chest or abdomen film (as in
injuries are: hit by knee, assault by animal (as in our our case).
case), and injury with a bicycle handle bar. Single IJP
occurs in less than 1% of blunt trauma patients.[6] Apart from physical examination, there are four methods
for diagnosis of bowel perforation: diagnostic peritoneal
Mechanisms of small bowel disruption with blunt lavage (DPL), computed tomography (CT) scan, focused
trauma include shearing forces, compression between abdominal sonography for trauma (FAST), and diagnostic
the abdominal wall and vertebral column, and blowout laparoscopy. Sometimes, DPL is more sensitive than CT
injury due to a sudden increase in intraluminal pressure imaging for diagnosis of isolated jejunal injury in the early
of bowel loop.[2] The incidence of small bowel injury hours; however, in many cases, it results in nontherapeutic
appears to be lower in children than in adults.[4] For the laparotomy. Several authors have reported that DPL is an
early diagnosis of IJP, detailed history (mechanism of important adjunct in cases where isolated jejunal injury
injury) and frequent clinical examination of the abdomen is suspected.[3] In late hours of injury, FAST and CT are
are extremely useful, particularly in unconscious better than DPL. FAST is readily available, reliable,

September 2013 | Vol 18| Issue 2 Journal of Mahatma Gandhi Institute of Medical Sciences
146 Goyal, et al.: Single jejunal blowout perforation following blunt abdominal trauma

repeatable, and radiation-free diagnostic tool. No doubt, clinical suspicion and the help of available appropriate
CT scan is the gold standard for assessment of blunt diagnostic tools like DPL/FAST are mandatory.
trauma, with a sensitivity of 92%, specificity of 94%,
positive predictive accuracy of 30%, negative predictive References
accuracy of 100%, and overall accuracy (validity) of
94%,[2] but has got limited role in the early hours of injury 1. Chiang WK. Isolated jejunal perforation from nonpenetrating
abdominal trauma. Am J Emerg Med 1993;11:473-5.
and in hemodynamically unstable patients.
2. Robbs JV, Moore SW, Pillay SP. Blunt abdominal trauma with
jejunal injury: A review. J Trauma 1980;20:308-11.
The role of laparoscopy in BAT is diagnostic as well as 3. Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D.
therapeutic in hemodynamically stable patients. Early Relatively short diagnostic delays (<8 hours) produce
diagnosis and timely surgical intervention offer the morbidity and mortality in blunt small bowel injury: An
best prognosis. 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
Open surgical repair or laparoscopic repair is the first in children: Influence of time to operative operation on
line of treatment. Septic peritoneal collection is drained outcome. Injury 2005;36:1029-33.
and saline lavage is done. Simple two-layer closure is 5. Munshi IA, DiRocco JD, Khachi G. Isolated jejunal perforation
usually adequate for single perforation of the small after blunt thoracoabdominal trauma. J Emerg Med
intestine (as done in our case). 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
Although the impact of operative delays on morbidity 1998;45:69-78.
and mortality has been unclear, a brief delays as little 7. Neugebauer H, Wallenboeck E, Hungerford M. Seventy cases
as 8 h can result in increased morbidity and mortality in of injuries of the small intestine caused by blunt abdominal
“missed” small bowel injury.[3] If small bowel perforation trauma: A retrospective study from 1970 to 1994. J Trauma
is treated earlier than 12 h, then the rate of complication 1999;46:116-21.
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.[3]
How to cite this article: Goyal S, Goyal S, Garg MK. Single
Conclusion jejunal blowout perforation following blunt abdominal
trauma: Diagnostic dilemma. J Mahatma Gandhi Inst Med Sci
2013;18:144-6.
The diagnosis of traumatic single IJP is challenging. For
Source of Support: Nil, Conflict of Interest: None declared.
most favorable results, strict monitoring, a high index of

Journal of Mahatma Gandhi Institute of Medical Sciences September 2013 | Vol 18| Issue 2