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Gastrointestinal perforations in children: a continuing challenge to nonoperative treatment of blunt abdominal trauma
1Department of Pediatric Surgery, Ege University, Faculty of Medicine, Izmir, Turkey.
Insights
Conservative management of pediatric trauma may delay diagnosis of hollow viscus perforations (HVP). Peritoneal signs are key indicators, and peritoneal lavage is highly sensitive for diagnosing HVP in children.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Diagnostic Imaging
Background:
- Conservative management is increasingly used for hemodynamically stable pediatric trauma patients.
- This approach may inadvertently delay the diagnosis of critical injuries like hollow viscus perforations (HVP).
Purpose of the Study:
- To determine if expectant management delays HVP diagnosis in pediatric trauma.
- To survey factors contributing to diagnostic delay.
- To reevaluate the efficacy of current diagnostic tools for HVP.
Main Methods:
- Retrospective review of 1,283 pediatric trauma admissions (1980-1994).
- Analysis of 34 patients operated for blunt abdominal trauma-induced HVP.
- Evaluation of diagnostic accuracy of physical exam (peritoneal signs), abdominal roentgenograms, ultrasound, and peritoneal lavage.
Main Results:
- Signs of peritoneal irritation were present in 32/34 patients.
- Abdominal roentgenograms detected free air in only 6/24.
- Ultrasound identified free fluid in 4/13 without solid organ injury.
- Peritoneal lavage was diagnostic in 8/9 patients.
- Average time from admission to OR was 24 hours.
- Mortality was 11/34, primarily due to head injury.
Conclusions:
- There appears to be a delay in diagnosing traumatic hollow viscus perforations in pediatric patients.
- Clinical signs of peritoneal irritation are the most reliable indicators of HVP.
- Peritoneal lavage demonstrates high diagnostic sensitivity for HVP and is recommended when abdominal signs persist.
Abstract:
The present trend towards conservative management of hemodynamically stable pediatric trauma patients may be increasing the risk of delay in the diagnosis of traumatic hollow viscus perforations (HVP). The purpose of this study is to determine whether there is a delay in the diagnosis of HVP because of expectant management. A survey of factors leading to diagnostic delay was also made and the value of current diagnostic tools were reevaluated. In 1,283 trauma admissions between 1980-1994, 34 patients were operated for HVP caused by blunt abdominal trauma. Sites of perforation were; stomach (four), duodenum (five), jejunum (12), ileum (nine), and jejunum/ileum (four). Signs of peritoneal irritation were positive in 32 of 34 patients. There was free air in only six of 24 abdominal roentgenograms. Free peritoneal fluid without solid organ injury was detected in only four out of 13 patients with ultrasound. Peritoneal lavage was diagnostic in eight of nine patients. Time from admission to operating room averaged 24 +/- 4.1 (mean +/- standard deviation) hours. Eleven patients died after the operation mostly because of accompanying head injury. Only two of the deaths were the result of sepsis originating from the perforated bowel. There is an apparent delay in the diagnosis of traumatic HVP in this series. Signs of peritoneal irritation are the most consistent findings of HVP after blunt abdominal trauma in children. Persistence of abdominal signs indicates peritoneal lavage, which has a high diagnostic sensitivity for HVP compared to other diagnostic modalities.