Pediatr Radiol (1992) 22:146-147
Pediatric Radiology 9 Springer-Verlag 1992
CT diagnosis of gastric rupture following blunt abdominal trauma in a child R. K. Tu a, R. J. Starshak 2, and B. B r o w n 3 z Department of Radiology, University of Wisconsin Hospital and Clinics, Clinical Science Center, 600 Highland Ave., Madison, WI 53792-3252, USA 2Department of Radiology, Children's Hospital of Wisconsin, 9000 W. Wisconsin Ave., Milwaukee, W153226, USA 3Department of Surgery, Children's Hospital of Wisconsin, 9000 W. Wisconsin Ave., Milwaukee, W153226, USA Received: 21 October 1991; accepted: 22 November 1991
Gastric p e r f o r a t i o n following blunt abdominal t r a u m a is rare in adults and rare in children. If this injury goes unrecognized, it is associated with significant morbidity and mortality. T h e c o m p u t e d tomographic (CT) findings of traumatic gastric perforation with surgical correlation, a review of the recent literature and a discussion of the specific mechanisms arepresented.
Case report A 4-year-old boy was struck by a car in a hitand-run accident. The child experienced a post-traumatic seizure and had an altered state of consciousness at the time of admission. Significant findings included a left femur fracture and abdominal distension. The only abnormal laboratory study was microscopic hematuria. Cranial CT was normal. Abdominal CT was significant for free intraperitoneal air which outlined the falciform ligament (Fig. 1). The nasogastric tube was floating free within the peritoneal cavity coursing through the ruptured gastric wall (Fig. 2). Heterogeneous fluid-fluid layer was noted within the peritoneal cavity, presumably from partially digested gastric contents. They were seen in the lateral gutters and the pelvis (Fig. 3). Other findings included a left renal pericapsular hematoma, renal fracture and splenic laceration (Fig. 4). At laparotomy, the nasogastrictubewas immediatelyidentifiedfloating free in the perito neal cavity. The entire abdomen was contaminated with gastric contents consisting of hot dogs, cola and assorted snacks. A 13 cm rent was noted along the greater curvature of the stomach. The defect was dosed in two layers and the abdomen was lavaged with saline.
Discussion Gastric perforation following blunt abdominal t r a u m a requires p r o m p t diagnosis and treatment. In children, diagnosis is difficult preoperatively since
Fig. 1. Supine scout film demonstrating intraperitoneal air that outlines the falciform ligament (arrows) Fig.2. Axial CT image showing free intraperitoneal air (curved arrow). The nasogastric tube ties in an intraperitoneal location (arrow) Fig. 3. Axial CT at level of pelvis demonstrating the fluid-fluidlevel from layering of intraperitonealgastric contents (arrow). Note fibrous cord remnants of the umbilical arteries that are outlined by intraperitonealfluid
(curvedarrow) Fig.4. Axial CT at level of kidneys demonstrating left capsular hematoma and fracture. Note free intraperitoneal air
associated injuries may be extensive and thorough exam m a y be less than ideal in this uncooperative patient group. Grosfeld et al. noted only 2 gastric injuries in their series of 53 children . A b d o m i nal pain and rigidity are consistent with
p e r i t o n e a l irritation form gastric contents which causes an i m m e d i a t e chemical peritonitis. A sequale of such a chemical burn is fluid sequestration that can result in d e h y d r a t i o n and hypovolemic shock .
147 This case illustrates t h e C T findings w h i c h are suggestive of gastric r u p t u r e : free s u b d i a p h r a g m a t i c air, v i s u a l i z a t i o n of an " o u t l i n e d " F a l c i f o r m l i g a m e n t , int r a p e r i t o n e a l nasogastric t u b e location, and i n t r a p e r i t o n e a l fluid-fluid layer. G a s t r i c p e r f o r a t i o n follows s e v e r e abr u p t p r e s s u r e a p p l i e d to a d i s t e n d e d stomach. A n e m p t y s t o m a c h is m o r e pliable and rests p r o t e c t e d b e h i n d t h e left costal margin. T h e full s t o m a c h is b e l o w the costal m a r g i n and m a y b e directly c o m p r e s s e d against the v e r t e b r a l c o l u m n . T h e a b r u p t i n c r e a s e in intragastric pressure l e a d s to d e h i s c e n c e of t h e gastric wall, m o s t o f t e n n e a r t h e g r e a t e r curvature. T h e r e is strong association of this injury with injury to m u l t i p l e o t h e r organs, especially t h e s p l e e n and kidney.
Conclusion T r a u m a t i c gastric p e r f o r a t i o n s are unc o m m o n , especially in children. C T m a y b e helpful in establishing an early diagnosis t h e r e b y d e c r e a s i n g t h e p e r i o d of p e r i t o n e a l c o n t a m i n a t i o n , sepsis and shock. This m a y also lessen i n t r a p e r i t o n e a l abscess f o r m a t i o n . This case is p r o b a b l y the first w h i c h illustrates t h e C T criteria of gastric p e r f o r a t i o n .
References 1. Grosfeld JL, Rescoria F J, West KW, Vane D W (1989) Gastrointestinal injuries in childhood: analysis of 53 patients. J Pediatr Surg 24:580-583
Literature in pediatric radiology The spectrum of Cantrell's syndrome. Vanamo, K. et al. (Children's Hosp., Univ., SF-00290 Helsinki, Finland) 6, 429 (1991) Cystic duplication of the jejunum presenting acutely following abdominal trauma. Shimotake, T. et al. (Div. of Surg., Children's Research Hosp., Prefectural Univ. of Med., 465, Kawaramachi-Hirokoji, Kamigyo-ku. Kyoto 602, Japan) 6,442 (1991) Immature ovarian teratoma with peritoneal gliomatosis and elevated serum alpha-fetoprotein associated with a second mature teratoma. Hokama, A. et al. (The First Dept. of Surg., School of Med., Univ. of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, Japan 903-01) 6, 448 (1991) Pneumologie (Stuttgart) A 13-year old boy with a mild form of cystic fibrosis and heterozygote gene mutation for Delta F 508. [In germ.] Hiort, O. et al. (Wiebicke, W., Rathenaustr. 5, W-2400 Liibeck, FRG) 45,910 (1991) Fibrotic alveolitis in a girl of seven years of age with autoimmunohaemolytic anaemia and autoimmunohepatitis. [In germ.] Paul, K. et al. (Univ.-Kinderklinik, Im Neuenheimer Feld 150~W-6900 Heidelberg, FRG) 45, 928 (1991) Plasma cell granuloma of the lung. [In germ.] Hammer, J. et al. (Rutishauser, M., Univ.-Kinderklinik, R6mergasse 8, CH-4058 Basel, Switzerland) 45, 932 (1991) Congenital chylothorax. [In germ.] Huber, A. et al. (Univ.-Kinderklinik, Langenbeckstr. 1, W-6500Mainz, FRG) 45, 939 (1991) Radiological diagnostics of congenitalmalformations of the tracheobronchial tree. [In germ.] St6ver, B. (Rad. Klinik der Albert-Ludwigs-Univ., Hugstetterstr. 55, W-7800 Freiburg i. Br., FRG) 45, 942 (1991) Indications for surgery on bronchopulmonary malformations in childhood. [In germ.] Nowak, W., Hofmann, A. (Med.-Pneumolog. Abt. mit Allergologie der Fachklinik, Zentrum ftir Atemwegserkrankungen, W-7988 Wangen im Allgfiu,FRG) 45, 952 (1991)
Radiologe (Berlin) Imaging of the salivary glands in children and adolescents. [In germ.] Diederich, S. et al. (Inst. f/ir Khnische Rad., WestffilischeWilhelms-Univ., Albert Schweitzer-Str. 33, W-4400 MOnster,FRG) 31, 550 (1991) Calcified aneurysm of the left coronary artery following Kawasaki's disease. [In germ.] Langen, H. J. et al. (Klinik ftir Rad. Diagn., Klinikum der RWTH, Pauwetsstr. 30, W-5100 Aachen, FRG) 31, 571 (1991)
2. Courcy PA, Soderstrom C, Brotman S (1984) Gastric rupture from blunt trauma. A plea for minimal diagnostics and early surgery. A m Surg 50:424-427 3. Vassy LE, Klecker RL, Koch E, Morse TS (1975) Traumatic gastric perforation in children from blunt trauma. J Trauma 15: 184-186
R. K. Tu, MD Department of Radiology University of Wisconsin Hospital and Clinics Clinical Science Center 600 Highland Ave. Madison, W153792-3252 USA
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SkeletalRadiology(Berlin) Hemorrhage associated with "bone crisis" in Gaucher's disease identified by magnetic resonance imaging. Horev, G. et al. (Dept. of Ped. Rad., Beilinson Med, Center, School of Med. TA Univ., Petach-Tikva 49100, Israel) 20, 479 (1991) Forearm deformities in multiple cartilaginous exostoses. Bock, G.W., Reed, M. H. (Dept. of Rad., Children's Hosp., 840 Sherbrook, St., Winnipeg, Manitoba, Canada R3A 1S1) 20, 483 (1991) Skeletal manifestations of granulocysfic sarcoma (chloroma). Hermann, G. et al. (Dept. of Rad., Box 1234,MountSinaiMed. Center, OneGustaveL. Levy Place, New York, NY 10029-6574, USA) 20, 509 (1991) Case report 693: Schneckenbecken dysplasia. Giedion, A. et al. (Dept. of Rad., Univ. Children's Hosp., Steinwiesstr. 75, CH-8032 Ztirich, Switzerland) 20, 534 (1991) Case report 694: Cervical paravertebral circumscribed myositis ossificans. L6pez Barea et al. (Dept. de Anatomia Patol., Hosp. La Paz, Paseo dela Castellana 261, E-28046 Madrid, Spain) 20, 539 (1991) Sclerosing bone dysplasias - a target-site approach. Greenspan, A. (Dept. of Rad. and Orthop. Surg., Univ., Davis School of Med., 2516 Stockton Blvd., Ticon II, Sacramento, CA 95817, USA) 20,561 (1991) Lumbar platyspondyly-characteristic sign of Ehlers-Danlos syndrome. Kozlowski, K. et al. (RAHC, Camperdown 2050, NSW, Australia) 20, 589 (1991) Clavicular overgrowth in association with cystic hygroma. Law, R J., Hall, C.M. (Dept. of Rad., St. Bartholomew's Hosp., West Smithfield, London ECIA 7BE, UK) 20, 597 (1991) Case report 701: prostaglandin E 1 (PGE1) periostitis. Rowley, R. E Lawson, J. P. (Dept. ofMed. Imaging, St. Peter's Hosp., 315 South Manning Blvd., Albany, NY 12208, USA) 20, 617 (1991) Case report 702: Langerhans cell histiocytosis (LCH) of the skin, skull, and mandible with calcifications in associated soft-tissue masses. Shenouda, N. E, Azouz, E. M.(Azouz, E. M., Dept. of Rad., McGill Univ. and The Children's Hosp., 2300 Tupper St., Montreal, Quebec, Canada H3H 1P3) 20, 620 (1991) Case report 703: multifocal osteosarcoma. Olson, P.N. et al. (Box 292 UMHC, Univ., Minneapolis, MN 55455, USA) 20,624 (1991)
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