Case Report

Late presentation of jejunal perforation after Thoracic trauma

Abstract

Jejunal perforation is extremely rare in trauma especially without initial involvement of the abdomen. We present the case of a delayed jejunal perforation after thoracic trauma with no initial indication of abdominal trauma in a 55-year- old man who was admitted to our department after a road traffic accident. The patient sustained thoracic trauma with rib fractures of the left hemithorax and hemopneumothorax and a mild head injury. On the fourth day of his In-hospital stay, he complained of severe abdominal pain and signs of acute abdomen were observed. He underwent emergency laparotomy where a perforation of the jejunum near the ligament of Treitz was noticed and sutured. His post- operative recovery was uneventful. Physicians treating trauma should always have a high degree of suspicion regarding rare abdominal injuries, with delayed presenta- tion, even if no abdominal involvement is noticed during the initial survey.

Jejunal injury is an uncommon finding after blunt abdominal trauma (BAT) due to high-energy, decelerating injuries [1]. Patients usually have multiple traumatic injuries that involve the abdomen or/and other systems. The jejunum may be perforated, transected, or devascularized [2]. Multi- ple sites of damage are usually found [3], whereas isolated perforation is extremely rare [4].

We present the case of a patient who presented with thoracic and cranial injury and developed acute abdomen due to an isolated jejunal perforation, 4 days after his admission. A 55-year-old man presented at our hospital’s emergency department (ED) after a side impact road traffic accident (RTA). He had his seat belt on. The initial evaluation revealed head and chest trauma. No seat belt marks were identified. His Glasgow Coma Scale was 15/15. Chest x-ray revealed left hemithorax rib fractures (5th-10th) and hemopneumothorax for which a chest tube was inserted (Fig. 1). The ultrasonography (FAST ultrasonography) was negative. All blood tests were normal. Because the patient

was hemodynamically normal, he was subjected to com- puted tomography (CT) of the head, chest and abdomen. Thoracic CT-verified CXR findings alongside with lung contusions. Abdominal CT was normal (Fig. 2). The patient was then admitted to our department for further investiga- tion. He was started on analgesia with intramuscular administration of pethidine 50 mg 4 times daily. The next day he had another ultrasonography performed, which was also negative and he was started on fluids by mouth, whereas his vitals and blood tests were normal. On his 4th posttraumatic day, he complained of abdominal pain located over the epigastric region. On examination, localized acute

Fig. 1 Chest x-ray of the patient during initial evaluation after the insertion of chest drainage tube in the left chest.

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abdomen was noted. A new CXR revealed air subdiaph- ragmatically (Fig. 3). The patient was subjected to laparotomy, where a complete but small perforation of the jejunum 10 cm away from the ligament of Treitz was noticed. No other injuries were identified. Enteric and inflammatory fluid and pseudomembranes were noticed in the area between the transverse colon and the ligament of Treitz. The jejunum was sutured in 2 layers with a 3/0 absorbable suture (Vicryl), the abdomen was thoroughly washed, and a drain was left near the site of the suturing. The drain was removed on the 5th postoperative day. The patient’s recovery was uneventful, and he was discharged on the 10th postoperative day.

In general, injuries of the hollow viscera due to BAT are not common [5-9], with isolated jejunal injury being far more uncommon [6,10].

RTA are the most important causes of jejunal injury, characterized by great decelerating forces [1,3,5,8], Seat belts seem to be important in preventing injuries of the hollow viscera [2], although such a role remains con- troversial [11].

Most cases of jejunal rupture appear with subdue clinical findings [1,6,9,10,12], as peritoneal irritation evolves gradually, due to the normal pH, low bacterial count, and inactive enzymes of the jejunal bowel content [9]. Patients mainly present with abdominal pain [13]. The time of presentation is usually within few hours after the injury [5,14]; however, the diagnosis is delayed because of the general condition of the patient [15] or because of concomitant injuries [2,4,5,8], and vigorous treatment is needed [5]. In our case, there was no suspicion of BAT whatsoever at presentation, eventually revealing itself 4 days after the injury. Cases of Delayed presentation of jejunal perforation after trauma are extremely rare [13].

Most trauma patients will be eventually started on analgesia and BAT may be masked. Mild analgesics may prove more helpful in diagnosis of rare traumatic injuries, at least at the initial steps of trauma management.

Fig. 2 Abdominal CT of the patient.

Fig. 3 Chest x-ray of the patient on the 4th day of his hospitalization after complaining for abdominal pain showing Free air subdiaphragmatically.

Pneumoperitoneum presenting with free subdiaphrag- matic air as expected in Visceral perforation may not appear in CXR performed at the ED [9,13]. Many authors [2,9] consider Diagnostic peritoneal lavage and an elevated alkaline liver phosphatase important diagnostic tools [16]. Pneumoperitoneum [3,12,14] or free peritoneal fluid without solid Organ injuries [5] may be observed in CT.

The main feeling is that most of the examinations may be inconclusive, and thus, serial abdominal physical examinations and observation of the patient still remain the key Diagnostic approach to hollow viscera injuries after BAT [10,13].

The treatment of jejunal perforations involves simple closure and drainage of the sutured area [3,8,9]. Posttraumatic stricture, formation of enterocutaneous fistula [13], and the risk of sepsis or peritonitis should always alert the surgeons [11]. Simple closure was adequate in our case. The common site of perforation is usually near the ligament of Treitz, which is the point of fixation of the proximal jejunum [12].

In conclusion, traumatic jejunal injury is difficult to diagnose, even with new imaging modalities, constituting clinical examination and observation as key diagnostic tools. Jejunal isolated perforations in polytrauma patients without BAT are extremely rare, and thus, the treating physicians should always be highly suspicious of this kind of injury, especially in cases where the mechanism of trauma involves a high-energy impact.

Vasileios K. Kouritas MD, PhD Efthimiou Matheos MD, PhD Ioannis Baloyiannis MD Michalis Spyridakis MD Department of Surgery Larissa University Hospital

41 110 Mezourlo Larissa, Greece

Case Report 1177.e3

E-mail addresses: [email protected],

[email protected], [email protected]

Nikolaos Desimonas MD Department of Cardiothoracic Surgery Larissa University Hospital

41 110 Mezourlo Larissa, Greece

Kostas Hatzitheofilou Department of Surgery Larissa University Hospital

41 110 Mezourlo Larissa, Greece

doi:10.1016/j.ajem.2009.02.018

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