Unusual case of viscus perforation following a freak accident
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.197921
Sir, We read with interest the article on small bowel perforations by Seth and Agarwal.[1] We present an unusual case of a 35-year-old woman who had a freak history of a ceiling fan and cement slab falling on her abdomen, followed by a delayed presentation of the acute abdomen and shall discuss the role of computed tomography (CT) in the early management of this patient. Blunt trauma to the abdomen causing hollow viscus injury is very uncommon (<5% of cases).[2] Perforation is usually caused by penetrating trauma, and the viscera that are commonly involved are stomach, small bowel, colon, and rectum. Involvement of the small bowel and mesentery is seen in 5% of blunt trauma cases.[2] There are high chances of hemorrhage and peritonitis that may lead to sepsis and multiple organ failure in such cases. Thus, to decrease the patient mortality and morbidity, early diagnosis and treatment are critical.[2] Establishing the diagnosis however can be challenging. A 35-year-old woman presented to the emergency ward with a freak history of a ceiling fan and slab that fell on her abdomen 2 days before presentation at our hospital. She was admitted to a local hospital and treated for her scalp injury. There was no history of loss of consciousness. On day 1, she did not have abdominal distension or pain. Progressively, she developed symptoms and was admitted here after 48 h. The patients' vitals were stable on presentation but complained of pain abdomen which was severe and diffuse. On examination of the abdomen, there was abdominal distension with diffuse guarding and tenderness. Bowel sounds were absent. The plain radiographs revealed a very subtle lucency, suggesting free air under the hemidiaphragm [Figure 1]a and [Figure 1]b.
CT of the abdomen was performed on an emergency basis, and the following impression was made based on the imaging ([Figure 2]a, [Figure 2]b and [Figure 2]d – abdomen window, [Figure 2]c lung window). Moderate pneumoperitoneum with air pockets anterior to the liver [Figure 2]c, straight arrow] and left hypochondrium in the interbowel region were observed. There was cecal wall thickening and edema in this region [[Figure 2]d, curved arrow]. There were also mild to moderate ascites predominantly in the pelvis and interbowel regions with few air pockets within which were summarized as features of hollow viscus perforation.
The patient was taken up for exploratory laparotomy under general anesthesia after taking high-risk consent. Intraoperatively, there was a circular rent in the bowel suggesting cecal perforation with fecal peritonitis along with sloughed and inflamed distal ileum and ascending colon [[Figure 3], white arrow]. Free fluid was noted and there was evidence of contusion over the right ovary. Right hemicolectomy was performed. The postoperative course was uneventful.
The use of CT for detection of mesenteric and bowel injury was first described in literature in articles published over three decades ago, i.e., in the early 1980s.[3] Since then, a number of comprehensive observations by radiologists have been published, but findings in surgical literature described CT unreliable.[3] However, with continuous evolution of CT, the sensitivity and specificity have increased, and now, the most significant traumatic injuries to the bowel and mesentery can be identified. According to a study conducted by Joseph et al., the most common hollow viscus organs injured were small bowel, followed by colon, duodenum, rectum, and stomach.[4] Small bowel and mesentery injuries are the third most common type of injury to abdominal organs, resulting from a blunt trauma.[2] The majority are caused by motor vehicle accidents, handlebar injury, and falls.[5] Usual causes of colon perforation include diverticulitis, carcinoma, iatrogenic perforation, abdominal trauma, and ingestion of foreign bodies.[6] Blunt trauma resulting from the fall of ceiling fan and the slab has not been reported so far in our knowledge and thus constitutes as a rare cause for acute abdomen due to preceding abdominal injury. Free intra-abdominal air detected by CT scan is an uncommon finding in cases of blunt trauma. Accumulation of air can be seen in the porta hepatis, mesentery or mesenteric veins, and portal vein after the bowel rupture. Mechanical ventilation, pulmonary barotrauma, peritoneal lavage prior to CT, pneumothorax, chest injury, entry of air via female genital tract ( Fallopian tube More Detailss), and intraperitoneal laceration of bladder secondary to cystography contribute to other causes for foci of intraperitoneal and extraluminal air.[2] Exact pathophysiological mechanism of traumatic blunt bowel injury is not well known. However, a few probable explanations have been stated in the texts, for example – barotrauma causes rupture of alveoli which in turn releases air that travels through the intestinal tissues to the roots of the lung and mediastinum and further into the parietal pleura causing pneumothorax or in rare instances when retroperitoneal air can rupture into the peritoneum causing free intraperitoneal air.[7] Sudden increase in pressure within the closed intestinal segment may explain antimesenteric perforation while shearing and tangential forces are most likely the reason for mesenteric injuries.[7] Recently, Marek et al. evaluated 78 patients and concluded that free air detected by CT is not always clinically significant.[8] A similar study conducted by Hefny et al. (2015) on 21 patients concluded that the decision of laparotomy should be taken after combining both radiological and clinical findings as free air detected by CT is not a very reliable finding for bowel perforation.[7] If note is made of other radiographic signs such as extraluminal contrast material, intramural air, bowel wall thickening, bowel wall enhancement, mesenteric infiltration, and intraperitoneal and retroperitoneal fluid along with pneumoperitoneum, it is highly predictive of injury and these patients should be explored.[2] Sometimes, free air can be due to microperforation of the bowel which may seal rapidly without clinical sequelae. This may explain the absence of bowel perforation and negative laparotomy in patients with pneumoperitoneum on imaging.[7] A study conducted by Hefny et al. stated that the presence of multiple free intraperitoneal air pockets measuring 10 mm or more, located in the right hypochondrium, the midline anteriorly and between the bowel loops should raise suspicion for bowel perforation.[7] Neideree et al. demonstrated an increase in acute respiratory distress syndrome and sepsis when there was >24 h delay in surgical intervention. In a more recent study, >5 h interval between the presentation and laparotomy was found to increase the incidence of death 3-fold.[4] A high index of suspicion is essential while evaluating a patient with blunt trauma. Multidetector CT use has become important adjunct in evaluation of hemodynamically stable blunt trauma patients. Advancement in CT technology has raised the sensitivity for detection of free intraperitoneal air. It is important for a surgeon to take a decision regarding the need of laparotomy after combining the imaging findings and clinical diagnosis. To conclude, pneumoperitoneum in cases of blunt trauma causing bowel perforation is rare but fatal. Understanding the mechanism responsible for such kind of injury is important so as to support the clinical findings and lead to an early diagnosis, which may aid in streamlining the approach for management of patient with the aim to reduce mortality and morbidity, and CT plays an unparalleled role in doing so. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3]
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