Gastrointestinal perforation following blunt abdominal trauma

To highlight the pertinent management problems of bowel perforation following blunt abdominal trauma.

A prospective descriptive study.

Hospital-based cohort over a nine year period in Jos University Teaching Hospital, Jos, Nigeria.

A total of 23 patients with bowel perforation out of 8,970 trauma victims with a mean age of 28.5 years.

Exploratory laparotomy, drainage of septic peritoneal fluid and wound saline lavage and closure of perforations were performed in all the 23 patients with clinical features and imaging signs suggestive of bowel perforation following blunt abdominal trauma. Femoral fractures were splinted and tube thoracostomy were carried out in four and two patients respectively.

There is an apparent delay in presentation and diagnosis of traumatic bowel perforation following blunt abdominal trauma. Signs of peritoneal sepsis remain the most consistent findings in our environment. The morbidity and mortality following blunt abdominal trauma and bowel perforation are high because of established peritonitis. Delayed presentation or large leakage of bowel content into the peritoneal cavity and the attendant ease with which peritonitis develops in the latter are factors responsible.

Delayed presentation (mean 3.05 days) was observed in seven of 23 patients. Eight patients had concomitant injuries; two to the head, four had right femoral fracture and two blunt chest injury. Features of peritonitis were present at initial evaluation in 19 patients. Seventeen patients were victims of motor vehicle accident. Radiological evidence of perforation (pneumoperitoneum) was present in only two of four patients with difficult diagnosis. Free peritoneal fluid without solid organ injury was detected in two patients with ultrasound. Diagnostic peritoneal lavage was, therefore, not used in any of our patients. The mean time from admission to laparotomy was six hours. Sites of perforations were: stomach (2), jejunum (9), ileum (8), jejunum/ileum (2) and colon (2). Sepsis originating from the perforated bowel was responsible for mortality in our patients who died in the perioperative period with concomitant injury playing significant role in three of 11 patients with such injuries.

Peritonitis following a bowel perforation after blunt abdominal trauma is often present at the time of presentation and diagnosis is usually made. In the few doubtful cases, often in patients presenting soon after trauma, X-ray and trans-abdominal ultrasonography will assist in making a diagnosis. Delayed presentation still accounts for a high mortality in bowel perforation following blunt abdominal trauma.