Injury (1992) 23, (7), 487-488
Printed in Great Britain
Small intestinal perforation
487
following minor trauma
G. S. W. Whiteley’, L. K. Penna and J. P. Bolton’ ‘Chase Farm Hospital, Enfield, Middl esex, UK and ‘St Richards Hospital, Chichester, West Sussex, UK
Small irztestinalperforation occurred in two patients aged 70 years and 88 years who had erperienced minor trauma by fripping or falling on the pavement. They both developed signs of generalized peritonitis and at laparotomy were found to have perforated the mid ileum There was no sign of direct abdominal trauma but they had suffered minor facial trauma as a result of the faa.
Resection of the affected portion of the ileum and primary anastomosis was performed. After the operation he was transferred to the intensive therapy unit, where he developed acute renal failure, deteriorated progressively and died 20 h postoperatively. Histology of the small bowel was consistent with an acute traumatic perforation.
Introduction
Case 2 An 8%year-old man, was previously well, with mild osteoarthritis treated with ibuprofen. He was walking outside and fell onto his face causing a laceration above his left eye and periorbital haematoma for which he attended the accident and emergency department. He also complained of generalized lower abdominal pain and inability to pass urine. He had vomited twice while in the department On examination he had a pulse rate of 8O/min and a blood pressure of 160/100 mmHg. Abdominal examination revealed no sign of direct abdominal trauma but his abdomen was rigid with generalized tenderness and inaudible bowel sounds. An erect chest radiograph did not reveal free gas in the abdomen. Laparotomy was performed and a single 1 cm perforation on the antimesenteric border of the ileum was noted. Contamination was minimal and there was no evidence of underlying bowel pathology. The perforation was biopsied prior to oversewing and peritoneal lavage was performed. The patient made an uneventful recovery and was discharged 10 days after his fall. Histology of the small intestine revealed findings consistent with a traumatic perforation.
Small intestinal perforation following major deceleration injury (Elkins and Bums, 1989) and direct blunt trauma (Braun et al., 1985; Dauterive et al., 1985) is well recognized. However, perforation of the small intestine may occur with relatively minor trauma as experienced by the following patients. Both patients were males and were fully ambulant with no previous gastrointestinal complaints. Perforation of a viscus was recognized clinically in both cases. Both patients underwent laparotomy at which similar injuries were seen.
Case reports Case 1 A 70-year-old, treated male hypertensive, with temporal lobe epilepsy, tripped on the pavement while walking and injured his chin. There was no loss of consciousness and no apparent neurological deficit. He attended the accident and emergency department- for attention to a graze to his chin. While in the department- he complained of a dull pain in his lower abdomen, which radiated to his testes. On examination he was tender in the lower abdomen with guarding but audible bowel sounds. Radiographs at that time did not show free gas in the abdomen. He was admitted to hospital and remained comfortable until 12 h later when he became dramatically short of breath, confused and suffered a sudden increase in abdominal pain. He had a tachycardia of IbOlmin and a blood pressure of 110/70mrnHg. He was centrally cyanosed with an arterial PO, measured at 55 mmHg on air. The abdomen was rigid with inaudible bowel sounds. An erect chesf radiograph showed free gas beneath the right hemidiaphragm. Laparotomy performed after resuscitation revealed a single 2.5 cm perforation on the antimesenteric border of the mid ileum with no obvious predisposing cause within the bowel wall. 4: 1992 Butterworth-Heinemann 0020-1383/92/070487-02
Ltd
Discussion Single small intestinal perforations were seen in both these patients, with no underlying bowel pathology. The only predisposing factor to perforation was a minor fall in the street sufficient to cause facial injury. No abdominal trauma was identified on history or examination. Both perforations were at a similar site and showed similar macroscopic features. Traumatic perforation from direct blunt trauma and seat belt type injuries has been described (Braun et al., 1985; Dauterive et al., 1985; Elkins and Bums, 1989) but is associated with substantial force. Perforation of the small intestine may also occur as a result of underlying intestinal conditions including Crohn’s
488
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 7
disease (Greenstein et al., 1985). Rarely, spontaneous perforation may occur (Putzki et al., 1985) or as a result of ingestion of slow-release preparations (Layer et al., 1987) and anti-inflammatory drugs (Deakin, 1988). It is interesting to note that the manifestation of perforation may be delayed after blunt trauma (Ross and Bicker&f, 1985; Winton et al., 1985), thus complicating the initial management. It is the aim of the authors to draw attention to small bowel perforation at a freely mobile part of the small intestine occurring after minor trauma.
Elkins S. K. and Burns R. P. (1989) Blunt intestinal
trauma associated with seat belt use. 1. 7&n. Med. Assoc. 82, 21. Greenstein A. J., Mann D., Sachar D. B. et al. (1985) Free perforation in Crohn’s disease. A survey of 99 cases. Am. 1. Gastroenterol. 80,682. Layer G. T., Scott-Jupp R. H., Maitra T. K. et al. (1987) Slow release potassium and perforation of Meckel’s diverticulum. Postgrad. Med. J. 63(737), 211. Putzki H., Ledwoch J., Dueben W. et al. (1985) Nontraumatic perforations of the small intestine. Am. J Surg. 149,375. Ross W. B. and Bickerstaff D. R. (1985) Late jejunal perforation following blunt trauma. Injury 16, 481. Winton T. L., Girotti M. J., Mancey P. N. et al. (1985) Delayed intestinal perforation after non-penetrating abdominal trauma. Can. J. Surg. 28, 437.
References Braun B. H., Breen P. C. and Brotman S. R. (1985) Small bowel injury following blunt trauma. Pa. Med. 88, 39. Dauterive A. H., Flancbaum L. and Cox E. F. (1985) Blunt intestinal trauma. A modem day review. Ann. Surg. 201, 198. Deakin M. (1988) Small bowel perforation associated with an excessive dose of slow release dicolfenac sodium. Br. Med. J 297(6646), 488.
Paper accepted 6 December
1991.
Requests for reprints should be addressed to: Mr G. S. W. Whiteley MS Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester Ml3 9WL, UK.
FRCS, University
Book review Limb Salvage. F. Langlais and B. Tomeno. Springer-Verlag, Germany. 038752861 X, DM 268, 1991, 823 pp. This extensive work of some 825 pages records the proceedings of the fifth international symposium on limb salvage held in 1989 and has over 300 contributors to 105 papers. The editors are to be congratulated on the effectiveness of the grouping of papers and their clear insistence that authors re-write their oral presentations into a standardized style for publication, including a detailed reference bibliography with each. The diagrams and photographs are of the usual high standard expected from this publisher. As expected, the book is almost entirely devoted to salvage in relation to oncology with only passing reference to trauma or to failed conventional prostheses. Such a work is always daunting to those not deeply involved with a sub-discipline so highly technical and specialised. It cannot be regarded as a textbook but merely an update on the start of the art. The index is short providing only a source for key words which lessens its value as a reference manual.
Progress in salvaging diseased limbs through non-mutilating surgery without jeopardising survival has been staggering. Some of the most fascinating aspects involve the development of osteo-integrable prostheses including factors to promote local bone formation and bone morphagenic protein with a biodegradable synthetic carrier. Others study the limitation of side effects of the necessary Xray and chemotherapeutic adjuvants in relation to the incorporation of massive allografts and to prosthetic fixation. It is a book that is hard to put down as each paper is a revelation in current thinking. How could the reader fail to be intrigued by three of the eleven sections being headed ‘Innovative’ covering materials, prostheses and procedures. This is not a book for the undergraduate but is essential reading for all studying for a higher diploma in orthopaedic surgery or specializing in orthopaedic oncology. It is strongly recommended to be on the shelves of unit libraries. It will be of considerable interest to view the next volume in two years time to assess the progress in this dramatically advancing field.
J. T. Coull
Printed in Great Britain
Small intestinal perforation
487
following minor trauma
G. S. W. Whiteley’, L. K. Penna and J. P. Bolton’ ‘Chase Farm Hospital, Enfield, Middl esex, UK and ‘St Richards Hospital, Chichester, West Sussex, UK
Small irztestinalperforation occurred in two patients aged 70 years and 88 years who had erperienced minor trauma by fripping or falling on the pavement. They both developed signs of generalized peritonitis and at laparotomy were found to have perforated the mid ileum There was no sign of direct abdominal trauma but they had suffered minor facial trauma as a result of the faa.
Resection of the affected portion of the ileum and primary anastomosis was performed. After the operation he was transferred to the intensive therapy unit, where he developed acute renal failure, deteriorated progressively and died 20 h postoperatively. Histology of the small bowel was consistent with an acute traumatic perforation.
Introduction
Case 2 An 8%year-old man, was previously well, with mild osteoarthritis treated with ibuprofen. He was walking outside and fell onto his face causing a laceration above his left eye and periorbital haematoma for which he attended the accident and emergency department. He also complained of generalized lower abdominal pain and inability to pass urine. He had vomited twice while in the department On examination he had a pulse rate of 8O/min and a blood pressure of 160/100 mmHg. Abdominal examination revealed no sign of direct abdominal trauma but his abdomen was rigid with generalized tenderness and inaudible bowel sounds. An erect chest radiograph did not reveal free gas in the abdomen. Laparotomy was performed and a single 1 cm perforation on the antimesenteric border of the ileum was noted. Contamination was minimal and there was no evidence of underlying bowel pathology. The perforation was biopsied prior to oversewing and peritoneal lavage was performed. The patient made an uneventful recovery and was discharged 10 days after his fall. Histology of the small intestine revealed findings consistent with a traumatic perforation.
Small intestinal perforation following major deceleration injury (Elkins and Bums, 1989) and direct blunt trauma (Braun et al., 1985; Dauterive et al., 1985) is well recognized. However, perforation of the small intestine may occur with relatively minor trauma as experienced by the following patients. Both patients were males and were fully ambulant with no previous gastrointestinal complaints. Perforation of a viscus was recognized clinically in both cases. Both patients underwent laparotomy at which similar injuries were seen.
Case reports Case 1 A 70-year-old, treated male hypertensive, with temporal lobe epilepsy, tripped on the pavement while walking and injured his chin. There was no loss of consciousness and no apparent neurological deficit. He attended the accident and emergency department- for attention to a graze to his chin. While in the department- he complained of a dull pain in his lower abdomen, which radiated to his testes. On examination he was tender in the lower abdomen with guarding but audible bowel sounds. Radiographs at that time did not show free gas in the abdomen. He was admitted to hospital and remained comfortable until 12 h later when he became dramatically short of breath, confused and suffered a sudden increase in abdominal pain. He had a tachycardia of IbOlmin and a blood pressure of 110/70mrnHg. He was centrally cyanosed with an arterial PO, measured at 55 mmHg on air. The abdomen was rigid with inaudible bowel sounds. An erect chesf radiograph showed free gas beneath the right hemidiaphragm. Laparotomy performed after resuscitation revealed a single 2.5 cm perforation on the antimesenteric border of the mid ileum with no obvious predisposing cause within the bowel wall. 4: 1992 Butterworth-Heinemann 0020-1383/92/070487-02
Ltd
Discussion Single small intestinal perforations were seen in both these patients, with no underlying bowel pathology. The only predisposing factor to perforation was a minor fall in the street sufficient to cause facial injury. No abdominal trauma was identified on history or examination. Both perforations were at a similar site and showed similar macroscopic features. Traumatic perforation from direct blunt trauma and seat belt type injuries has been described (Braun et al., 1985; Dauterive et al., 1985; Elkins and Bums, 1989) but is associated with substantial force. Perforation of the small intestine may also occur as a result of underlying intestinal conditions including Crohn’s
488
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 7
disease (Greenstein et al., 1985). Rarely, spontaneous perforation may occur (Putzki et al., 1985) or as a result of ingestion of slow-release preparations (Layer et al., 1987) and anti-inflammatory drugs (Deakin, 1988). It is interesting to note that the manifestation of perforation may be delayed after blunt trauma (Ross and Bicker&f, 1985; Winton et al., 1985), thus complicating the initial management. It is the aim of the authors to draw attention to small bowel perforation at a freely mobile part of the small intestine occurring after minor trauma.
Elkins S. K. and Burns R. P. (1989) Blunt intestinal
trauma associated with seat belt use. 1. 7&n. Med. Assoc. 82, 21. Greenstein A. J., Mann D., Sachar D. B. et al. (1985) Free perforation in Crohn’s disease. A survey of 99 cases. Am. 1. Gastroenterol. 80,682. Layer G. T., Scott-Jupp R. H., Maitra T. K. et al. (1987) Slow release potassium and perforation of Meckel’s diverticulum. Postgrad. Med. J. 63(737), 211. Putzki H., Ledwoch J., Dueben W. et al. (1985) Nontraumatic perforations of the small intestine. Am. J Surg. 149,375. Ross W. B. and Bickerstaff D. R. (1985) Late jejunal perforation following blunt trauma. Injury 16, 481. Winton T. L., Girotti M. J., Mancey P. N. et al. (1985) Delayed intestinal perforation after non-penetrating abdominal trauma. Can. J. Surg. 28, 437.
References Braun B. H., Breen P. C. and Brotman S. R. (1985) Small bowel injury following blunt trauma. Pa. Med. 88, 39. Dauterive A. H., Flancbaum L. and Cox E. F. (1985) Blunt intestinal trauma. A modem day review. Ann. Surg. 201, 198. Deakin M. (1988) Small bowel perforation associated with an excessive dose of slow release dicolfenac sodium. Br. Med. J 297(6646), 488.
Paper accepted 6 December
1991.
Requests for reprints should be addressed to: Mr G. S. W. Whiteley MS Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester Ml3 9WL, UK.
FRCS, University
Book review Limb Salvage. F. Langlais and B. Tomeno. Springer-Verlag, Germany. 038752861 X, DM 268, 1991, 823 pp. This extensive work of some 825 pages records the proceedings of the fifth international symposium on limb salvage held in 1989 and has over 300 contributors to 105 papers. The editors are to be congratulated on the effectiveness of the grouping of papers and their clear insistence that authors re-write their oral presentations into a standardized style for publication, including a detailed reference bibliography with each. The diagrams and photographs are of the usual high standard expected from this publisher. As expected, the book is almost entirely devoted to salvage in relation to oncology with only passing reference to trauma or to failed conventional prostheses. Such a work is always daunting to those not deeply involved with a sub-discipline so highly technical and specialised. It cannot be regarded as a textbook but merely an update on the start of the art. The index is short providing only a source for key words which lessens its value as a reference manual.
Progress in salvaging diseased limbs through non-mutilating surgery without jeopardising survival has been staggering. Some of the most fascinating aspects involve the development of osteo-integrable prostheses including factors to promote local bone formation and bone morphagenic protein with a biodegradable synthetic carrier. Others study the limitation of side effects of the necessary Xray and chemotherapeutic adjuvants in relation to the incorporation of massive allografts and to prosthetic fixation. It is a book that is hard to put down as each paper is a revelation in current thinking. How could the reader fail to be intrigued by three of the eleven sections being headed ‘Innovative’ covering materials, prostheses and procedures. This is not a book for the undergraduate but is essential reading for all studying for a higher diploma in orthopaedic surgery or specializing in orthopaedic oncology. It is strongly recommended to be on the shelves of unit libraries. It will be of considerable interest to view the next volume in two years time to assess the progress in this dramatically advancing field.
J. T. Coull
