Delayed Recognition of Multiple Small Bowel Perforations and Mesenteric Lacerations Following Combined Blunt and...

Small bowel and mesenteric injuries (SBMI) following abdominal trauma are challenging to diagnose, particularly when initial imaging is non-definitive and multiple distracting injuries are present. Bowel injury may remain occult during the initial assessment, and delayed recognition can result in significant morbidity and mortality. A 39-year-old previously healthy male construction worker sustained a penetrating injury to the right lumbar region after a heavy object fell from approximately 2-2.5 meters, with retained steel fragments and associated blunt abdominal trauma. He was hemodynamically stable on presentation, with a negative focused assessment with sonography for trauma (FAST) examination. Initial computed tomography (CT) demonstrated a right psoas intramuscular hematoma containing small air locules with surrounding soft tissue stranding. No pneumoperitoneum, mesenteric hematoma, or definitive radiological evidence of hollow viscus injury was identified. After wound debridement, he was admitted for close observation. His abdominal symptoms initially improved, but on post-injury Day 3 he developed worsening abdominal pain. Examination at that time showed abdominal distension, rigidity, newly developed abdominal wall bruising, and palpable subcutaneous crepitus. Repeat CT demonstrated significant pneumoperitoneum and peritonitis. Diagnostic laparoscopy was performed and converted to laparotomy following identification of intestinal content. At laparotomy, there was diffuse four-quadrant peritonitis with multiple distal ileal perforations and mesenteric lacerations. The involved ileal segment was resected, followed by stapled side-to-side anastomosis, washout, and drain placement. The patient recovered without major complications and was discharged on postoperative day nine. This case highlights the limitations of initial CT imaging in detecting bowel injury, particularly in combined trauma involving retroperitoneal and musculoskeletal injuries. The exact timing of the bowel perforations in this patient could not be established, and the injuries may have been initially occult before becoming clinically apparent. Serial clinical monitoring and a low threshold for repeat imaging are critical. Early repeat imaging or diagnostic laparoscopy should be considered in patients with persistent or concerning abdominal findings despite non-definitive initial imaging. A high index of suspicion for SBMI should be maintained following combined blunt and penetrating trauma, even when initial imaging is non-definitive. Continued clinical reassessment and timely further investigation are important when abdominal findings persist or recur.