Delayed Onset of Intestinal Unrecognized ByJerry
M. Hardacre
II, Karen W. West,
Obstruction in Children After Seat Belt Injury
Frederick R. Rescorla.
Indianapolis, l The increased use of child safety seats and seat belt restraints has significantly reduced the incidence of severe head injuries associated with motor vehicular accidents. However, an increase in the number of both acutely recognized intestinal perforations and delayed obstructions due to ischemic strictures has been noted. This report describes two children with delayed onset of intestinal obstruction related to the “seat belt syndrome” who presented with bilious emesis 3 to 6 weeks following an unrecognized lap belt injury. At laparotomy. a volvulus around an omental band adherent to a resolving traumatic mesenteric hematoma was the basis of the obstruction in both cases. The volvulus resulted in a stricture in each instance that required resection and end-to-end anastomosis. The diagnosis of posttraumatic intestinal obstruction should be suspected in children who develop nausea and bilious emesis following motor vehicular accidents in which they were wearing lap belts. @ 1990 by W.B. Saunders Company. INDEX WORDS: Seat belt syndrome; intestinal obstruction; blunt abdominal trauma.
T
RAUMA IS the leading cause of death in children under the age of 15 in the United States.‘** With the passage of mandatory restraint laws for younger children in all 50 states, the mortality from motor vehicular accidents (MVAs) has decreased by 16.6% from 1980 to 1984 (the last year for which data are presently available).3 However, the use of the various restraint devices has resulted in a number of seat belt-related intestinal injuries.4*5 Most of these injuries are of acute onset. Delayed presentation of small bowel obstruction related to posttraumatic ischemic intestinal strictures has been reported in adults and is now being recognized in the pediatric age group as well.6 This report describes two children with delayed onset intestinal obstruction due to a volvulus following an unrecognized lap belt injury. CASE
REPORTS
Dennis W. Vane, and Jay L. Grosfeld
Indiana performed and demonstrated a small bowel volvulus about an omental adhesion to the base of the jejunal mesentery. Following reduction of the volvulus, two strictures were noted in the proximal jejunum at the points of volvulus. Two limited resections with end-to-end anastomosis were performed. The patient had an uneventful postoperative course and was discharged on day 7.
Case 2 While vacationing, a previously healthy Syear-old boy was involved in a MVA facing forward wearing an adult lap belt in the front seat of the car. At a local hospital, he was evaluated for abdominal pain after the accident with an abdominal computed tomography (CT) scan. This showed a splenic laceration that was conservatively treated with observation. The patient was discharged a few days later from the triaging hospital and was followed at home by his local pediatrician. Three weeks following the injury he developed bilious emesis that was initially attributed to a “viral illness.” His symptoms persisted and he was referred to the James Whitcomb Riley Hospital for Children for evaluation. Left upper quadrant tenderness was noted on physical examination. An abdominal CT scan was obtained, which showed duodenal dilatation and a healed splenic fracture. A small bowel contrast enteroclysis study demonstrated passage of the contrast material through a dilated duodenum. Due to persistence of the intermittent bilious vomiting the patient was taken to the operating room. At the time of laparotomy, a volvulus about an omental band adhered to a resolving traumatic mesenteric hematoma was observed. Following reduction of the volvulus, a proximal jejunal stricture was observed. This was resected and an end-to-end anastomosis was performed, He was discharged on postoperative day 6 following uneventful recovery. DISCUSSION
The development of child restraints, three-point shoulder harnesses, and lap belts have altered the types of injuries associated with blunt abdominal trauma incurred in MVAs. Previously, severe head and solid visceral organ damage accounted for most of the morbidity and mortality associated with passengerrelated injuries. I-4 The spectrum of injuries associated with wearing the various passenger restraints has been termed the “seat belt syndrome” and includes intesti-
Case 1 A previously healthy 8-year-old girl was involved in a high-speed MVA facing forward, wearing an adult back seat lap belt. Her only demonstrable injury was an L4 vertebral compression fracture, which was treated with a brace and bedrest. Symptoms of anorexia, nausea, vomiting, and subsequent weight loss began 2 weeks after the injury and were initially attributed to a grieving process due to the death of a sibling in the same accident. Bilious emesis developed 6 weeks after the injury. Erect and recumbant abdominal radiographs showed a step-ladder pattern consistent with small bowel obstruction. She was referred to the James Whitcomb Hospital for Children. Indiana University Medical Center. A laparotomy was Journal of Pediatric Sorg~y, Vol 25, No 9 (September), 1990: pp 967-969
From the Section of Pediatric Surgery, Department of Surgery, Indiana University Medical Center, and the James Whitcomb Riley Hospital for Children. Indianapolis, IN. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois, October 21-23.1989. Address reprint requests to Jay L. Grosfeld, MD, Surgeon-inChief; J. W. Riley Hospitalfor Children, 702 Barnhill Dr. Indianapolis, IN 46202-5200. o I990 by W.B. Saunders Company. 0022-34&Y/90/2509-0009$03.00/O
967
968
HARDACRE ET AL
nal perforations, mesenteric disruptions, and lumbar fracture-dislocations (chance fractures). More common in children than adults, the associated “seat belt sign” includes contusions, petechiae, and abrasions across the chest or lower abdomen.7 The majority of the visceral injuries (perforations) are recognized acutely and treated promptly according to the findings on exploratory laparotomy.8~10 Delayed presentations of intestinal injuries following traffic accidents attributed to seat belt use are well-documented in the adult literature. Isolated cases of blunt small bowel injury have been attributed to the deceleration of abdominal viscera resulting in tears of the mesentery, compression of the gut against the spine, and contusions, all of which could produce ischemic changes in the bowel wall.“-‘6 Onset of symptoms in adults have occurred several weeks to months following the accident. In some cases, the symptoms have been erroneously attributed to Crohn’s disease.6S’7 Reports of similar injuries in children are less common however, the etiology (ischemia) of the stricture is presumed the same.‘*.19
The two children in this report presented with delayed onset intestinal obstruction as a result of midsmall bowel volvulus around an omental band adherent to a resolving traumatic mesenteric hematoma. The strictures occurred in the compressed areas of the proximal and distal segments of the bowel involved in the torsion, and were successfully treated with primary resection and anastomosis. In one instance, a mesenteric rent was also repaired. Posttraumatic intestinal obstruction should be suspected in children who develop signs and symptoms consistent with a partial small bowel obstruction (nausea, bilious emesis, and abdominal pain) following seat belt-related blunt abdominal trauma. The history, physical examination, and plain abdominal radiographs are helpful in arriving at the correct diagnosis. Small bowel contrast studies (enteroclysis) may be necessary to delineate the site of obstruction in selected cases. Pediatric physicians should be aware of the potential hazards of seat belt injuries in children. Long-term follow-up of children sustaining a seat belt injury is recommended.
REFERENCES 1. Cobb LM, Vincour CD, Wagner CW, et al: Intestinal perforation due to blunt trauma in children in an era of increased nonoperative treatment. J Trauma 26:461-463, 1986 2. Polen MR, Friedman CD: Automobile injury-Selected risk factors and prevention in the health care setting. JAMA 259:77-80, 1988 3. Decker MD, Dewey MJ, Hutcheson RH, et al: The use and efficacy of child restraint devices. JAMA 252:2571-25751984 4. Denis MD, Allard M, Atlas H, et al: Changing trends with abdominal injury in seatbelt wearers. J Trauma 23:1007-1008, 1983 5. Agran PF, Dunkle PE, Winn DG: Injuries to a sample of seatbelted children evaluated and treated in a hospital emergency room. J Trauma 27:58-64.1987 6. Taylor D, Magee F, Stordy JN, et al: Small bowel injury simulating Crohn’s disease after blunt abdominal trauma. J Clin Gastroenterol9:99-101, 1987 7. Vanderslius R, O’Connor HMC: The seat belt syndrome. Can Med Assoc J 137:1023-1024,1987 8. Kakos GS, Grosfeld JL, Morse TS: Small bowel injuries in children after blunt abdominal trauma. Ann Surg 174:238-241, 1971 9. Reilly A, Marks M, Nance F, et al: Small bowel trauma in children and adolescents. Am Surg 51:132-135, 1985 10. Kovacs GZ, Davies MRQ, Saunders W, et al: Hollow viscus
rupture due to blunt trauma. Surg Gynecol Obstet 163:552-554, 1986 11. Marks CG, Nolan DJ, Piris NJ, et al: Small bowel strictures after blunt abdominal trauma. Br J Surg 66:663-664, 1979 12. Lien GS, Mori M, Enjoi M: Delayed post traumatic ischemic stricture of the small intestine: A clinicopathologic study of four cases. Acta Pathol Jpn 37:1367-1374, 1987 13. Bryner UM, Longerbeam JK, Reeves CD: Posttraumatic ischemic stenosis of the small bowel. Arch Surg 115:1039-1041, 1980 14. Shively E, Pearlstein L, Kinnaird DW, et al: Post-traumatic intestinal obstruction. Surgery 79:612-617, 1976 15. Kulowski J, Rost WB: Intra-abdominal injury from safety belt in auto accident. Arch Surg 73:970-971, 1956 16. Pohl MJ, Cook WJ: Small bowel stenosis after seat belt injury. Med J Aust 2: 156, 1980 17. Braun PG, Dion Y: Intestinal stenosis following seat belt injury. J Pediatr Surg 8:549-550, 1973 18. Gillet M, Phillips E, Adlog M: Les Stenoses cicatrielles de l’intestiinis grele apies contusion de l’abdomen. J Chir 93:469-477, 1967 19. Brownstein EG: Blunt abdominal trauma simulating Crohn’s disease of the terminal ileum. Aust N Z J Surg 54:287-289, 1984
Discussion B. Harris (Boston, MA): Enough reports of acute injuries from the seat belt syndrome have prompted the Department of Transportation to require auto manufacturers to include torso restraints in the back seats in the 1990 model cars. Back in the bad old days when we
used surgical exploration for everybody with abdominal injuries or positive peritoneal lavage, we saw many patients whose sole operative finding was a mesenteric hematoma. Few, if any, of those patients ever got into this sort of trouble. I wonder if you could tell us what’s
INTESTINAL
OBSTRUCTION
AFTER SEAT BELT INJURY
different about the mesenteric hematoma in the seat belt syndrome patient that makes adhesions compared with those other “ordinary” trauma patients? J. Hardacre (response): I’m not sure as to why there would be any significant difference. These two children were treated in the space of 3 weeks last summer. We have neither seen such cases since nor before these occurrences. I don’t have any theories; however, similar cases have been noted in the adult literature. J. Templeton (Philadelphia, PA): Just an enhancement of what Dr Harris was saying. The problems with the lap belt alone extend much worse to paralysis and so on. The cost estimate for the companies to put the shoulder component in is $14 for each new car. Because of my own concerns, it took me 2 months going to the auto dealer to get them to agree to retrofit the shoulder component and it cost $150. J. Hardacre (response): That’s an interesting observation. 1 suspect as we enter the 1990s the auto manufacturers will provide the mandatory shoulder restraints in the back seats. We all sincerely hope that this will reduce the number of children with severe passenger acquired injuries. K. Newman (Washington, DC): I’d like to commend you on an excellent presentation of very interesting
969
data. We’ve seen 10 patients with the acute form of this syndrome that you’re commenting on and found that the CT scan in those patients was unreliable in the diagnosis of both the intestinal injury and the spinal injury. Looking back at the course and the diagnostic tests in these two patients, can you pinpoint any findings that might have allowed you to make the diagnosis sooner? J. Hardacre (response): Both patients were treated outside of our institution with their initial injury. When they developed bowel obstruction, the symptoms were initially attributed to viral illness in the second boy and in the first patient, they were attributed to signs of depression caused by the death of her sister in the same accident. You must have a high index of suspicion concerning this form of the seat belt syndrome. At the recent national conference on pediatric trauma, surgeons from Vanderbilt would disagree with you and state that CAT scan does increase the chance of picking up acute intestinal injury. I don’t think that this issue is ever going to be resolved. In Indiana, we do not use peritoneal lavage for children as we do in adults and we rely on the CAT scan and repeated physical examination to try to pick up these acute intestinal injuries.
M. Hardacre
II, Karen W. West,
Obstruction in Children After Seat Belt Injury
Frederick R. Rescorla.
Indianapolis, l The increased use of child safety seats and seat belt restraints has significantly reduced the incidence of severe head injuries associated with motor vehicular accidents. However, an increase in the number of both acutely recognized intestinal perforations and delayed obstructions due to ischemic strictures has been noted. This report describes two children with delayed onset of intestinal obstruction related to the “seat belt syndrome” who presented with bilious emesis 3 to 6 weeks following an unrecognized lap belt injury. At laparotomy. a volvulus around an omental band adherent to a resolving traumatic mesenteric hematoma was the basis of the obstruction in both cases. The volvulus resulted in a stricture in each instance that required resection and end-to-end anastomosis. The diagnosis of posttraumatic intestinal obstruction should be suspected in children who develop nausea and bilious emesis following motor vehicular accidents in which they were wearing lap belts. @ 1990 by W.B. Saunders Company. INDEX WORDS: Seat belt syndrome; intestinal obstruction; blunt abdominal trauma.
T
RAUMA IS the leading cause of death in children under the age of 15 in the United States.‘** With the passage of mandatory restraint laws for younger children in all 50 states, the mortality from motor vehicular accidents (MVAs) has decreased by 16.6% from 1980 to 1984 (the last year for which data are presently available).3 However, the use of the various restraint devices has resulted in a number of seat belt-related intestinal injuries.4*5 Most of these injuries are of acute onset. Delayed presentation of small bowel obstruction related to posttraumatic ischemic intestinal strictures has been reported in adults and is now being recognized in the pediatric age group as well.6 This report describes two children with delayed onset intestinal obstruction due to a volvulus following an unrecognized lap belt injury. CASE
REPORTS
Dennis W. Vane, and Jay L. Grosfeld
Indiana performed and demonstrated a small bowel volvulus about an omental adhesion to the base of the jejunal mesentery. Following reduction of the volvulus, two strictures were noted in the proximal jejunum at the points of volvulus. Two limited resections with end-to-end anastomosis were performed. The patient had an uneventful postoperative course and was discharged on day 7.
Case 2 While vacationing, a previously healthy Syear-old boy was involved in a MVA facing forward wearing an adult lap belt in the front seat of the car. At a local hospital, he was evaluated for abdominal pain after the accident with an abdominal computed tomography (CT) scan. This showed a splenic laceration that was conservatively treated with observation. The patient was discharged a few days later from the triaging hospital and was followed at home by his local pediatrician. Three weeks following the injury he developed bilious emesis that was initially attributed to a “viral illness.” His symptoms persisted and he was referred to the James Whitcomb Riley Hospital for Children for evaluation. Left upper quadrant tenderness was noted on physical examination. An abdominal CT scan was obtained, which showed duodenal dilatation and a healed splenic fracture. A small bowel contrast enteroclysis study demonstrated passage of the contrast material through a dilated duodenum. Due to persistence of the intermittent bilious vomiting the patient was taken to the operating room. At the time of laparotomy, a volvulus about an omental band adhered to a resolving traumatic mesenteric hematoma was observed. Following reduction of the volvulus, a proximal jejunal stricture was observed. This was resected and an end-to-end anastomosis was performed, He was discharged on postoperative day 6 following uneventful recovery. DISCUSSION
The development of child restraints, three-point shoulder harnesses, and lap belts have altered the types of injuries associated with blunt abdominal trauma incurred in MVAs. Previously, severe head and solid visceral organ damage accounted for most of the morbidity and mortality associated with passengerrelated injuries. I-4 The spectrum of injuries associated with wearing the various passenger restraints has been termed the “seat belt syndrome” and includes intesti-
Case 1 A previously healthy 8-year-old girl was involved in a high-speed MVA facing forward, wearing an adult back seat lap belt. Her only demonstrable injury was an L4 vertebral compression fracture, which was treated with a brace and bedrest. Symptoms of anorexia, nausea, vomiting, and subsequent weight loss began 2 weeks after the injury and were initially attributed to a grieving process due to the death of a sibling in the same accident. Bilious emesis developed 6 weeks after the injury. Erect and recumbant abdominal radiographs showed a step-ladder pattern consistent with small bowel obstruction. She was referred to the James Whitcomb Hospital for Children. Indiana University Medical Center. A laparotomy was Journal of Pediatric Sorg~y, Vol 25, No 9 (September), 1990: pp 967-969
From the Section of Pediatric Surgery, Department of Surgery, Indiana University Medical Center, and the James Whitcomb Riley Hospital for Children. Indianapolis, IN. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois, October 21-23.1989. Address reprint requests to Jay L. Grosfeld, MD, Surgeon-inChief; J. W. Riley Hospitalfor Children, 702 Barnhill Dr. Indianapolis, IN 46202-5200. o I990 by W.B. Saunders Company. 0022-34&Y/90/2509-0009$03.00/O
967
968
HARDACRE ET AL
nal perforations, mesenteric disruptions, and lumbar fracture-dislocations (chance fractures). More common in children than adults, the associated “seat belt sign” includes contusions, petechiae, and abrasions across the chest or lower abdomen.7 The majority of the visceral injuries (perforations) are recognized acutely and treated promptly according to the findings on exploratory laparotomy.8~10 Delayed presentations of intestinal injuries following traffic accidents attributed to seat belt use are well-documented in the adult literature. Isolated cases of blunt small bowel injury have been attributed to the deceleration of abdominal viscera resulting in tears of the mesentery, compression of the gut against the spine, and contusions, all of which could produce ischemic changes in the bowel wall.“-‘6 Onset of symptoms in adults have occurred several weeks to months following the accident. In some cases, the symptoms have been erroneously attributed to Crohn’s disease.6S’7 Reports of similar injuries in children are less common however, the etiology (ischemia) of the stricture is presumed the same.‘*.19
The two children in this report presented with delayed onset intestinal obstruction as a result of midsmall bowel volvulus around an omental band adherent to a resolving traumatic mesenteric hematoma. The strictures occurred in the compressed areas of the proximal and distal segments of the bowel involved in the torsion, and were successfully treated with primary resection and anastomosis. In one instance, a mesenteric rent was also repaired. Posttraumatic intestinal obstruction should be suspected in children who develop signs and symptoms consistent with a partial small bowel obstruction (nausea, bilious emesis, and abdominal pain) following seat belt-related blunt abdominal trauma. The history, physical examination, and plain abdominal radiographs are helpful in arriving at the correct diagnosis. Small bowel contrast studies (enteroclysis) may be necessary to delineate the site of obstruction in selected cases. Pediatric physicians should be aware of the potential hazards of seat belt injuries in children. Long-term follow-up of children sustaining a seat belt injury is recommended.
REFERENCES 1. Cobb LM, Vincour CD, Wagner CW, et al: Intestinal perforation due to blunt trauma in children in an era of increased nonoperative treatment. J Trauma 26:461-463, 1986 2. Polen MR, Friedman CD: Automobile injury-Selected risk factors and prevention in the health care setting. JAMA 259:77-80, 1988 3. Decker MD, Dewey MJ, Hutcheson RH, et al: The use and efficacy of child restraint devices. JAMA 252:2571-25751984 4. Denis MD, Allard M, Atlas H, et al: Changing trends with abdominal injury in seatbelt wearers. J Trauma 23:1007-1008, 1983 5. Agran PF, Dunkle PE, Winn DG: Injuries to a sample of seatbelted children evaluated and treated in a hospital emergency room. J Trauma 27:58-64.1987 6. Taylor D, Magee F, Stordy JN, et al: Small bowel injury simulating Crohn’s disease after blunt abdominal trauma. J Clin Gastroenterol9:99-101, 1987 7. Vanderslius R, O’Connor HMC: The seat belt syndrome. Can Med Assoc J 137:1023-1024,1987 8. Kakos GS, Grosfeld JL, Morse TS: Small bowel injuries in children after blunt abdominal trauma. Ann Surg 174:238-241, 1971 9. Reilly A, Marks M, Nance F, et al: Small bowel trauma in children and adolescents. Am Surg 51:132-135, 1985 10. Kovacs GZ, Davies MRQ, Saunders W, et al: Hollow viscus
rupture due to blunt trauma. Surg Gynecol Obstet 163:552-554, 1986 11. Marks CG, Nolan DJ, Piris NJ, et al: Small bowel strictures after blunt abdominal trauma. Br J Surg 66:663-664, 1979 12. Lien GS, Mori M, Enjoi M: Delayed post traumatic ischemic stricture of the small intestine: A clinicopathologic study of four cases. Acta Pathol Jpn 37:1367-1374, 1987 13. Bryner UM, Longerbeam JK, Reeves CD: Posttraumatic ischemic stenosis of the small bowel. Arch Surg 115:1039-1041, 1980 14. Shively E, Pearlstein L, Kinnaird DW, et al: Post-traumatic intestinal obstruction. Surgery 79:612-617, 1976 15. Kulowski J, Rost WB: Intra-abdominal injury from safety belt in auto accident. Arch Surg 73:970-971, 1956 16. Pohl MJ, Cook WJ: Small bowel stenosis after seat belt injury. Med J Aust 2: 156, 1980 17. Braun PG, Dion Y: Intestinal stenosis following seat belt injury. J Pediatr Surg 8:549-550, 1973 18. Gillet M, Phillips E, Adlog M: Les Stenoses cicatrielles de l’intestiinis grele apies contusion de l’abdomen. J Chir 93:469-477, 1967 19. Brownstein EG: Blunt abdominal trauma simulating Crohn’s disease of the terminal ileum. Aust N Z J Surg 54:287-289, 1984
Discussion B. Harris (Boston, MA): Enough reports of acute injuries from the seat belt syndrome have prompted the Department of Transportation to require auto manufacturers to include torso restraints in the back seats in the 1990 model cars. Back in the bad old days when we
used surgical exploration for everybody with abdominal injuries or positive peritoneal lavage, we saw many patients whose sole operative finding was a mesenteric hematoma. Few, if any, of those patients ever got into this sort of trouble. I wonder if you could tell us what’s
INTESTINAL
OBSTRUCTION
AFTER SEAT BELT INJURY
different about the mesenteric hematoma in the seat belt syndrome patient that makes adhesions compared with those other “ordinary” trauma patients? J. Hardacre (response): I’m not sure as to why there would be any significant difference. These two children were treated in the space of 3 weeks last summer. We have neither seen such cases since nor before these occurrences. I don’t have any theories; however, similar cases have been noted in the adult literature. J. Templeton (Philadelphia, PA): Just an enhancement of what Dr Harris was saying. The problems with the lap belt alone extend much worse to paralysis and so on. The cost estimate for the companies to put the shoulder component in is $14 for each new car. Because of my own concerns, it took me 2 months going to the auto dealer to get them to agree to retrofit the shoulder component and it cost $150. J. Hardacre (response): That’s an interesting observation. 1 suspect as we enter the 1990s the auto manufacturers will provide the mandatory shoulder restraints in the back seats. We all sincerely hope that this will reduce the number of children with severe passenger acquired injuries. K. Newman (Washington, DC): I’d like to commend you on an excellent presentation of very interesting
969
data. We’ve seen 10 patients with the acute form of this syndrome that you’re commenting on and found that the CT scan in those patients was unreliable in the diagnosis of both the intestinal injury and the spinal injury. Looking back at the course and the diagnostic tests in these two patients, can you pinpoint any findings that might have allowed you to make the diagnosis sooner? J. Hardacre (response): Both patients were treated outside of our institution with their initial injury. When they developed bowel obstruction, the symptoms were initially attributed to viral illness in the second boy and in the first patient, they were attributed to signs of depression caused by the death of her sister in the same accident. You must have a high index of suspicion concerning this form of the seat belt syndrome. At the recent national conference on pediatric trauma, surgeons from Vanderbilt would disagree with you and state that CAT scan does increase the chance of picking up acute intestinal injury. I don’t think that this issue is ever going to be resolved. In Indiana, we do not use peritoneal lavage for children as we do in adults and we rely on the CAT scan and repeated physical examination to try to pick up these acute intestinal injuries.
