Gastrointestinal tract perforation due to blunt abdominal trauma

A retrospective clinical study was performed to evaluate the etiology, diagnosis, and management of gastrointestinal tract perforation (GITP) due to blunt abdominal trauma (BAT) in order to find a predictor to avoid delay in diagnosis. Thirty-five children with GITP out of 805 BAT victims (4.3%) over a 21-year period formed the study group. Different parameters including preoperative (mechanism of injury, abdominal and X- ray findings at presentation, diagnostic modalities), operative (type and site of GITP, intra-abdominal associated injuries, surgical method), and postoperative (complications, mortality) status were analyzed. The patients were subdivided according to their initial clinical presentation as group I: evidence of peritonitis (n = 19, 54%); group II: abdominal findings such as distension, minimal tenderness, and guarding (n = 10, 29%); and group III: normal abdominal findings (n = 6, 26%). These groups were also statistically compared to each other with regard to the parameters mentioned above. The Mann-Whitney U, Wilcoxon rank-sum, and Kruskal-Wallis tests were used for statistical analysis. P < 0.05 was considered to be statistically significant. There were 28 boys and 7 girls; the mean age was 8.2 +/- 2.4 years. Mechanisms of injury were motor vehicle accidents (MVA) (60%), falls (26%), and bicycle accidents (BA) (14%). Group I patients presented with significantly higher transaminase levels and white blood cell counts than groups II and III. Group I patients and MVA victims were operated upon significantly earlier than group III patients and BA victims because of significantly earlier development of clinical signs of peritonitis. A significantly higher number of multiple perforations was encountered in Group I and MVA victims than in groups II and III and BA victims. The presence of multiple perforations correlated significantly with the earlier development of clinical signs of peritonitis. The analysis of site of perforation with regard to the other parameters did not differ significantly. Fifty-four percent (n = 19) of the patients presented with peritonitis; a pneumoperitoneum was detected in 46% (n = 16). Diagnosis was accomplished by plain radiographs, ultrasound, computed tomography, and, most importantly, frequent abdominal examination of the patient. The sites of perforation were the stomach (4), duodenum (2), jejunum (11), ileum (12), jejunum and ileum (3), colon (2), and ileum and colon (1). Simple closure was the most common surgical procedure (n = 21), followed by resection and anastomosis (n = 12) and simple closure plus creation of a proximal ostomy (n = 2). Two deaths (5.7%) were directly due to head injuries. Our experience revealed that in spite of advanced imaging and laboratory modalities, frequent evaluation of the patient by an experienced surgeon is still the most important tool for early diagnosis and appropriate treatment. A child with BAT should be an inpatient and a high index of suspicion is always required, even in the presence of normal abdominal findings.