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Blunt intestinal injury in children. Diagnostic and therapeutic considerations
A G Kurkchubasche1, D G Fendya, T F Tracy
1Department of Surgery, St Louis University Health Sciences Center, Mo., USA.
Insights
Computed tomography (CT) and physical exams can identify blunt abdominal trauma in children. Subtle CT findings can complement physical exams for earlier diagnosis and intervention of intestinal injuries.
Area of Science:
- Pediatric Surgery
- Radiology
- Trauma Care
Background:
- Blunt abdominal trauma in children can lead to significant intestinal injuries.
- Early and accurate diagnosis is crucial for optimal patient outcomes.
- Computed tomography (CT) and physical examination are key diagnostic tools.
Purpose of the Study:
- To identify computed tomographic (CT) findings in children with blunt trauma and known intestinal injuries.
- To correlate CT findings with initial physical examination findings.
- To improve the timely diagnosis and intervention of pediatric intestinal injuries.
Main Methods:
- Retrospective review of pediatric patients (<18 years) with blunt intestinal injuries.
- Analysis of clinical data, physical examination findings, and CT scans.
- Correlation of imaging findings with surgical outcomes.
Main Results:
- Twenty-two pediatric patients with blunt intestinal injuries were identified.
- CT findings like pneumoperitoneum and contrast extravasation were uncommon but diagnostic.
- Subtle CT signs such as free pelvic fluid, bowel wall thickening, and fluid-filled loops were more frequent indicators.
- These subtle CT findings, combined with physical examination, aided in earlier surgical exploration.
Conclusions:
- Both physical examination and CT scans can independently diagnose intestinal injury in about 25% of cases.
- Subtle CT findings can significantly enhance physical examination, leading to more timely intervention.
- Improved diagnostic strategies can reduce complications associated with delayed diagnosis.
Objectives:
To identify computed tomographic (CT) findings in children who have experienced blunt trauma and who have known intestinal injuries and to correlate these findings with the findings of the initial physical examination.
Design:
A retrospective review of children (aged < 18 years) known to have an intestinal injury as a consequence of blunt trauma.
Setting:
A university-affiliated children's hospital with a level 1 pediatric trauma center.
Patients:
Children younger than 18 years who were admitted for examination of injuries or for management of complications related to intestinal injuries.
Interventions:
Clinical and radiographic evaluation and laparotomy for intestinal injuries other than duodenal hematoma.
Main Outcome Measures:
The identification and correlation of relevant findings during the physical examination, on the CT scan, and during surgery. The assessment of intervals from injury to diagnosis and intervention and the description of associated injuries.
Results:
Twenty-two patients sustained intestinal injuries as a result of blunt trauma. Most (15) of the patients were passengers injured in motor vehicle crashes; 14 of these patients were wearing seat belts. Focal blows to the abdomen from bicycle handlebars, hockey sticks, or falls onto blunt objects were implicated in the remaining patients. For 19 of the 22 patients, the initial physical examination was conducted at Cardinal Glennon Children's Hospital, St Louis, Mo, and 18 of the 19 patients underwent a concurrent CT evaluation. Peritonitis was found in 5 of these 18 patients. Tenderness on physical examination was noted in 9 of the 18 patients (tenderness was not noted in 3 patients, and 1 patient had unreliable examination findings due to a cervical spinal cord injury). Computed tomographic findings of pneumoperitoneum and extravasation of enteral contrast material were uncommon but diagnostic (in 5 patients). Free fluid in the pelvis in the absence of a solid organ injury, bowel wall thickening, and fluid-filled loops of bowel were more frequently useful signs of possible intestinal injury (in 9 of the 18 patients) and led to earlier exploration when used in conjunction with physical examination as an indication for surgery. Most injuries were treated with segmental resection or suture repair, but enterostomies were required in 2 patients. Complications (i.e., the need for enterostomy and fascial dehiscence) were seen as a result of late or missed diagnosis, which could occur as late as 4 to 6 weeks after injury as intestinal obstruction due to stricture.
Conclusions:
The initial physical examination findings and CT evaluation can independently identify the presence of intestinal injury in approximately 25% of cases. In the remainder of cases, the awareness of the more subtle findings of bowel injury on a CT scan can complement the physical examination findings and potentially lead to a more timely intervention for bowel injury.