J Forensic Sci, September 2014, Vol. 59, No. 5 doi: 10.1111/1556-4029.12460 Available online at: onlinelibrary.wiley.com
CASE REPORT PATHOLOGY/BIOLOGY
Basappa S. Hugar,1 M.D., D.N.B.; Girishchandra P. Yajaman,1 M.D.; Sunilkumar Kainoor,1 M.B.B.S.; and Akshith Raj S. Shetty,1 M.B.B.S.
Death Due to Isolated Jejunal Tear Following Blunt Abdominal Trauma
ABSTRACT: Small intestinal injury following blunt abdominal trauma has been widely reported. Isolated jejunal tear which is caused by
blunt abdominal trauma is rare and is most often seen in road traffic accidents. Here, we report a case of isolated jejunal tear in a 24-year-old male truck driver. He was admitted to a tertiary care hospital in a South Indian Metropolitan city with complaints of acute abdominal pain and tiredness following alleged accidental blunt trauma sustained to abdomen due to steering wheel impact. An isolated jejunal tear and adjacent mesenteric contusion and tear were missed by the treating physician even after preliminary investigations, and thus, the conservative management was instituted. The condition deteriorated gradually, and he succumbed to death. The autopsy revealed transverse tear of jejunum almost involving whole of its circumference on the antimesenteric border and peritonitis. Proper use of radio-diagnostic techniques and timely undertaken explorative laparotomy would have saved the life.
KEYWORDS: forensic science, forensic pathology, blunt abdominal trauma, road traffic accident, isolated jejunal tear, peritonitis The intestine can be ruptured with or without external wound; this fact was well known since the time of Aristotle who is quoted as saying slight blow to abdomen can cause rupture of the intestine without injury to the skin (1). Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Injuries of small bowel comprise about one quarter of blunt and penetrating abdominal trauma. Intestinal disruptions can be due to a variety of types of blunt trauma, with automobile collisions or accidents being the most common etiologic agent. Intestine is the third most commonly injured organ in blunt trauma (2). Identification of serious intra-abdominal pathology is often challenging. Blunt abdominal trauma producing intraperitoneal injury usually presents acutely, necessitating laparotomy for intestinal perforation or mesenteric vascular injury (3). In the absence of shock and peritonitis, patients with blunt abdominal injury may be treated conservatively. Steering wheel injuries leading to abdominal solid organ injury is rare. Steering wheel induced lower abdominal injuries encompasses contusions and lacerations of varying severity and frequency in the mesentery, the small and large bowels, the spleen, and the cecum (4). Isolated small bowel mesentery injury is rare. Mesenteric injury may not cause clinical manifestations (5). Most of the patients present with abdominal pain, tenderness, and distension. However, the features will be vague at initial examinations and become obvious only on repeated abdominal examinations. Isolated lesions of the small intestine can occur after steering wheel trauma, and the mesenteric injuries might remain undiagnosed after blunt abdominal trauma (6). One such case with no obvious 1 Department of Forensic Medicine, MS Ramaiah Medical College, Bangalore 560054, India. Received 13 Mar. 2013; and in revised form 22 June 2013; accepted 29 June 2013.
external abdominal injuries which proved fatal due to an isolated jejunal injury following blunt abdominal trauma in a road traffic accident is being reported here. Case Report A 24-year-old male truck driver was admitted to the hospital with alleged history of blunt abdominal trauma sustained due to steering wheel impact in a road traffic accident. He had severe abdominal pain and was in shock. His abdomen was slightly distended, and tenderness was present. His blood parameters revealed low hemoglobin (9 g/dL). The erect X-ray of the abdomen did not show free gas, although ultrasonography revealed free fluid in the peritoneum (but no free gas). It was documented that CT scan of abdomen was not carried out due to noncooperation and irritability of the patient. The general condition deteriorated gradually with continued tachycardia, hypotension, and SPO2 fluctuating (30–50%) in spite of conservative supportive treatment, and he died on the 3rd day after admission. The body was subjected for medico-legal autopsy after 4 h of death. Anterior abdominal muscles were contused. There was an isolated tear of the jejunum and the peritoneal cavity contained 300 mL of bile and bloodstained fluid. (Fig. 1 and 2) There was a transverse tear located on the antimesenteric border and involved almost the entire circumference (Fig. 3) and was situated 130 cms away from gastro-duodenal junction with a contusion of 8 9 6 cm over the adjoining mesentery. No other external and internal injuries were observed. Stomach contained 50 mL of clear fluid, with no unusual smell, and mucosa was normal. Opinion as to cause of death was furnished as “Death due to Peritonitis as a result of isolated jejunal tear consequent upon blunt abdominal injury sustained”. © 2014 American Academy of Forensic Sciences
HUGAR ET AL.
FIG. 1––Transversely torn jejunum and adjacent contused and torn mesentery.
FIG. 2––Bile and blood stained peritoneal fluid and contused anterior abdominal wall muscles.
FIG. 3––The transverse tear in the jejunum on the antimesenteric border involving whole of its circumference.
Discussion Annan in 1837 reported the first case of intestinal rupture secondary to blunt trauma in America (6). Seventy-five percent of the blunt abdominal trauma cases are caused by motor vehicle accidents (7). Although small bowel injuries have been reported to be the third most common injuries in blunt abdominal trauma, they occur in