Table of Contents  
LETTER TO THE EDITOR
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 103-106  

Unusual case of viscus perforation following a freak accident


1 Department of Radiodiagnosis, KMC, Manipal University, Mangalore, Karnataka, India
2 Department of Surgery, KMC, Manipal University, Mangalore, Karnataka, India

Date of Web Publication9-Jan-2017

Correspondence Address:
Dr. Santosh P. V. Rai
Department of Radiodiagnosis, KMC, Manipal University, Mangalore, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.197921

Rights and Permissions

How to cite this article:
Rai SP, Sharma H, Bhat R, Prabhu S. Unusual case of viscus perforation following a freak accident. Med J DY Patil Univ 2017;10:103-6

How to cite this URL:
Rai SP, Sharma H, Bhat R, Prabhu S. Unusual case of viscus perforation following a freak accident. Med J DY Patil Univ [serial online] 2017 [cited 2022 Sep 25];10:103-6. Available from: https://www.mjdrdypu.org/text.asp?2017/10/1/103/197921

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.
Figure 1: Plain radiographs of the abdomen (a) and chest (b) a faint lucency under the right hemidiaphragm

Click here to view


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.
Figure 2: Axial sections of computed tomography of the abdomen in the Abdomen window (a and b) and lung window (c, straight arrow) and abdomen window (a and b) free air in the peritoneal cavity suggesting hollow viscus perforation. Computed tomography of the pelvis (d) cecal wall thickening (thick-curved arrow)

Click here to view


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.
Figure 3: Intraoperative photograph of the colectomy specimen shows perforation of the cecum and surrounding gangrenous area (straight arrow)

Click here to view


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.

 
  References Top

1.
Seth S, Agrawal KK. Small bowel perforations: Review of 33 cases. Med J DY Patil Univ 2016;9:186-9.  Back to cited text no. 1
  Medknow Journal  
2.
Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics 2006;26:1119-31.  Back to cited text no. 2
    
3.
Brody JM, Leighton DB, Murphy BL, Abbott GF, Vaccaro JP, Jagminas L, et al. CT of blunt trauma bowel and mesenteric injury: Typical findings and pitfalls in diagnosis. Radiographics 2000;20:1525-36.  Back to cited text no. 3
    
4.
Joseph DK, Kunac A, Kinler RL, Staff I, Butler KL. Diagnosing blunt hollow viscus injury: Is computed tomography the answer? Am J Surg 2013;205:414-8.  Back to cited text no. 4
    
5.
Pimenta de Castro J, Gomes G, Mateus N, Escrevente R, Pereira L, Jácome P. Small bowell perforation and mesentery injury after an unusual blunt abdominal trauma – Case report. Int J Surg Case Rep 2015;7C: 51-3.  Back to cited text no. 5
    
6.
Lovece A, Asti E, Sironi A, Bonavina L. Toothpick ingestion complicated by cecal perforation: Case report and literature review. World J Emerg Surg 2014;9:63.  Back to cited text no. 6
    
7.
Hefny AF, Kunhivalappil FT, Matev N, Avila NA, Bashir MO, Abu-Zidan FM. Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: Experience from a community-based hospital. Injury 2015;46:100-4.  Back to cited text no. 7
    
8.
Marek AP, Deisler RF, Sutherland JB, Punjabi G, Portillo A, Krook J, et al. CT scan-detected pneumoperitoneum: An unreliable predictor of intra-abdominal injury in blunt trauma. Injury 2014;45:116-21.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
References
Article Figures

 Article Access Statistics
    Viewed2001    
    Printed39    
    Emailed0    
    PDF Downloaded126    
    Comments [Add]    

Recommend this journal