Case Presentation Kings county Hospital Center

M & M Conference June 2006

71M presented to KCHC, s/p MVA .

Patient was a restrained driver who denied any LOC

At the time of initial evaluation , he complained of right chest and flank pain.

He stated that he had a head on collision with a parked vehicle as he lost control.

PMHx : significant for HTN, CAD NIDDM and CRI.

PSHx : Patient had right sided neck dissection for ? Skin cancer (Hx unclear )

Physical EaminationHEEN :

b/l equal and reactive pupils, small contusion on the forhead .GCS 15.

Chest :decreased breath sounds on the right side .tenderness on palpation on the right flank and right chest.

Abdomen:BS + , seat belt sign noted on the anterior abdominal wall. No gaurding.

Extremities:b/l equal pulses ,no long bone deformities

Back: no evidence of sipnal tenderness ,no contusions noted.

Rectal:no gross blood, N tone.

Vital on presentation

BP : 150/87 mmHgPulse : 115 sinusGCS 15

Work up Labs:

ABGCBCCHEM Amylase U/A

ECHO :CTA :EKG :Troponins:

CT scan of Chest

CT scan of Chest :Right sided heamothoraxRib fractures

CT scan of Abdomen

Patient had placement of right sided Chest tube , about 200ml of gross blood noted at the time of insertion .

Patient was transferred to the SICU for further management.

During the SICU admission , patient developed type 2 respiratory failure.

HD# 3 patient started on BiPAP

He was statrted on regular diet on HD # 5

On HD # 6 , patient developed hypotention, abdominal distention and vague abdominal pain.

Intubated for airway protection , Patient started on pressors, followed by fluid resuscitation DPL done at the bed side – equivocal

Patient was emergently taken for CT scan.

CT scan of Abdomen (HD#6)

Patient was emergently taken to OR

Operative findings: Perforation of the ceacum with gross peritonitis Large hematoma ( transmural) involving the ceacum.The hematoma extending to the right mesocolon with compromised blood supply to the proximal half of the ascending colon.

Procedure : right hemicolectomy with ilieostomy

POD# 1 Patient did poorly in the SICU , in spite of maximal pressor support.

He eventually succumbed to Sepsis, On code full ACLS protocol followed.

Patient was pronounced.

Patient’s family refused autopsy.

Delayed Colonic Perforation following blunt abdominal

traumaEmmanuel Amulraj, MD

SUNY Downstate Medical Center

April 2006

Or Is the real question :

Delay in diagnosis of intestinal perforation in blunt abdominal trauma ?

OR

Delayed presentation of intestinal perforation in abdominal trauma ?

IntroductionSammuel Annan – Reported the first case of intestinal rupture following in blunt abdominal trauma in 1837.

Counseller and McCormack gave evidence to the “fixed point” theory in 1935

Most publications dealing with blunt abdominal trauma are based on few cases collected over many years.

Simple reasoning dictates that different mechanisms cause different injuries.

Colon injury occurs in 2% to 15% of patients having blunt abdominal trauma.

noted that a severe direct force is usually required to produce colon injuries.

Most of these injuries are due tomotor vehicle collisions (74%), and

the incorrect placement of safety belts has been implicated as an additional risk factor.

Regardless of restraint usage, associated injuries are common. •Carrillo EH, Somberg LB, Ceballos CE, et al: Blunt traumatic injuries to the colon and rectum.

•J Am Coll Surg 1996; 183:548-552

Possible mechanisms of hollow organ injury from blunt trauma include

crush injury between the vertebrae and anterior abdominal wall

tangential tears at relatively fixed points along the bowel

and a sudden increase in intraluminal pressure.

Although not consistent among reported series, colonic injury from blunt trauma appears evenly distributed.

Bugis et al, in their study of 16 patients with blunt colon injury, found primarily left-sided injuries

yet, Howell et al reviewed 19 cases and found that the transverse colon was most frequently injured

Bugis SP, Blair NP, Letwin ER: Management of blunt and penetrating colon injuries. Am J Surg 1992; 163:547-550

Howell HS, Bartizal JF, Freeark RJ: Blunt trauma involving the colon and rectum. J Trauma 1976; 16:624-632

Hemorrhagic contusion is the most frequent type of injury to the colon.

followed by serosal tears, which occur most commonly in the transverse colon.

Severe injuries occur more commonly in the sigmoid, right colon, and cecum, where frank rupture or devitalization from vascular compromise may result.

Because of the force required to injure the colon, other intra- and extra-abdominal injuries often coexist.

Injury to the transverse colon appears to have more associated injuries than other sites of colon injury

In the series reported by Dauterive et al,the most frequently encountered intra-abdominal injuries involved

the liver 64%, spleen 52% small bowel mesentery 48%. Involvement of the transverse colon also increased the likelihood of pancreaticoduodenal injuries.

The most frequently associated extra-abdominal injuries were skeletal 53% facial 33% neurologic 32% thoracic 10%

Dauterive AH, Flancbaum L, Cox EF: Blunt intestinal trauma. Ann Surg 1985; 201:198-203

The importance of physical examination in the diagnosis of colonic perforation cannot be overstated.

In 1984, Maull and Reath described 20 patients with hollow visceral injury.

All patients who were conscious at the time of admission complained of abdominal pain and/or had signs of peritoneal irritation.

The pitfall, of course, is that many injured patients are unresponsive when first encountered, may be affected by alcohol or other drugs, or have sustained a closed head injury, compromising the reliability of their clinical assessment.

In such circumstances, further investigation is warranted.

The seat belt sign Presence of which increases the likelihood of intraabdominal injuries , however the absence does not exclude it !

Seat belt-induced trauma to the small bowelWorld Journal of Surgery

Issue: Volume 9, Number 5 October 1985 , 794 - 797

Diagnostic peritoneal lavage done soon after blunt abdominal trauma may also miss a perforated hollow viscus.

Presumably, this is related to an initial absence of an inflammatory response.

The presence of excessive leukocytes (>500/mm[3]) in the effluent is highly suggestive of bowel injury.

The presence of vegetable matter is also suggestive.

In a report on the utility of DPL, Fang et al described the importance of the cell count ratio.

The cell count ratio was defined as the ratio between white blood cell count and red blood cell count in the lavage fluid, divided by the ratio of the same parameters in the peripheral blood.

A cell count ratio >/=1 predicted hollow organ perforation with a specificity of 97% and a sensitivity of 100%.

Ultrasonography and laparoscopy are additional diagnostic techniques available to the clinician, but both lack the sensitivity to aid in early diagnosis.

Fang JF, Chan RJ, Lin BC:Cell-count ratio: new criterion of diagnostic peritoneal lavage for detection of hollow organ perforation.

J Trauma 1998; 45:540-544

CT Vs DPLCT and diagnostic peritoneal lavage (DPL) may be helpful in confirming blunt intestinal injury, but both have limitations.

The role of CT in diagnosing hollow viscus injury after blunt abdominal trauma remains controversial, with previous studies reporting both high accuracy and poor results.

Helical CT scanning is very accurate in detecting bowel and mesenteric injuries, as well as in determining the need for surgical exploration in bowel injuries.

This study was performed to determine the diagnostic accuracy ofhelical computed tomography in detecting bowel and mesenteric injuries after blunt abdominal trauma in a large cohort of patients (150).

Computed tomography had an overall sensitivity of 94% in detecting bowel injury and 96% in detecting mesenteric injury.

`Surgical bowel cases were correctly differentiated in 64 of 74 cases (86%), and surgical mesenteric cases were correctly differentiated fromnonsurgical in 57 of 76 cases (75%).

However, it is less accurate in predicting the need for surgicalexploration in mesenteric injuries alone.

Helical Computed Tomography of Bowel and Mesenteric Injuries.Journal of Trauma-Injury Infection & Critical Care. 51(1):26-36, July 2001.Killeen, Karen L. MD

CT findings of intestinal rupture include pneumoperitoneum (without an intrathoracic source or previous peritoneal lavage)

gas in the mesentery, bowel wall, or retroperitoneum; and extraluminal extravasation of contrast material.

Other findings suggestive of bowel rupture include thickening of the bowel wall, anterior pararenal fluid, or free intraperitoneal fluid without a known source.

Lung windows to r/o free air Free air as seen on CT scan

CT Scan finding Jejunal thickening

Suggestive of duodenal / jejunal injury (arrows)

Ascending colon laceration.

CT abdominal scan demonstrates thickening of the lower ascending colon (arrows).

Correlation of US with CT scan findings

B = bladder, FL = fluid. Transverse US scan of the pelvis demonstrates a small amount of free fluid in the rectouterine pouch.

CT scan of the pelvis demonstrates fluid in the rectouterine pouch (arrow), with loops of bowel anteriorly.

FAST / Ultrasound

US Vs CT Rothlin et al calculated the sensitivity of US to be 98% for identifying free fluid and 41% for identifying solid organ injury

Sherbourne et al identified a group of patients with visceral injury;

26% of these patients had no hemoperitoneumdetected at screening US.

Rothlin MA, Naf R, Amgwerd M, et al.

Ultrasound in blunt abdominal and thoracic trauma. J Trauma 1993; 34:488-495

Sherbourne CD, Shanmuganathan K, Mirvis SE, et al.Visceral injury without hemoperitoneum: a limitation of screening abdominal sonography for trauma.

Emerg Radiol 1997; 4:349-354

Intra-abdominal Free Fluid without Solid Organ Injury in Blunt Abdominal Trauma: An Indication for Laparotomy.Journal of Trauma-Injury Infection & Critical Care. 52(6):1134-1140, June 2002.

The finding of more than trace amounts of free fluid in the absence of solid organ injury in BAT is often associated with clinically significant visceral injury.

Early laparotomy is recommended for these patients28 of 1,367 patients met inclusion criteria (2%)

21 patients underwent exploratory laparotomy (75%).

which for 16 was therapeutic (76%): bowel injuries were found in 10 patients, mesentery injuries in 6, and injuries to solid organs in 3.

In 5 patients, laparotomy was nontherapeutic.

Those with more than a trace of free fluid were significantly more likely to have a therapeutic procedure.

7 patients were observed, of whom 2 failed nonoperative management and underwent therapeutic laparotomies within 24 hours of admission for missed colon, splenic, and hepatic injuries.

The presence of abdominal seat belt bruising or a Chance-type fracture in the study patients was associated with a 90% and 100% therapeutic laparotomy rate, respectively.

Computed Tomographic Scanning and Selective Laparoscopy in the Diagnosis of Blunt Bowel Injury: A Prospective Study.Journal of Trauma-Injury Infection & Critical Care. 58(4):696-703, April 2005.Mitsuhide, Kitano MD

During the study period, 399 of 1,074 patients admitted for blunt torso injuries were enrolled in this study.

11 patients underwent emergency celiotomy and 11 underwent LP immediately after admission to the emergency department. 1 nontherapeutic laparotomy was performed among the patients who underwent celiotomy.

The LPs revealed 7 bowel perforations and 1 mesenteric laceration. After a repeat CT scan,

3 and 7 of the patients underwent laparotomy and LP, respectively.

4 bowel perforations were found by LP.

The remaining 198 patients were treated conservatively, and no complications related to a delayed BBI diagnosis occurred

Risk of late perforation in intestinal contusions caused by explosive blast Authors: CRIPPS N.P.J.1; COOPER G.J.Source: British Journal of Surgery, Volume 84, Number 9, September 1997, pp. 1298-1303(6)

Background Despite the predominance of superficial injuries after explosive blast exposure, major morbidity or mortality among immediate survivors is caused by delayed perforation of intestinal mural contusions.

Previous studies have suggested that small bowel and colonic contusions larger than 10 mm in diameter are at high risk.

This experimental study aimed to identify contusions at high risk of late perforation.

Methods Histological features of injury were classified in 188 blast-induced intestinal contusions in 16 anaesthetized Large White pigs.

ResultsSome 16 per cent of small bowel and 12 per cent of colonic contusions were at high risk of late perforation.

Small bowel contusions larger than 15 mm in diameter had a worse histological grading than those smaller than 15 mm

Contusions that extended over more than half the bowel circumference and those affecting the mesenteric border were more severe injuries.

Colonic contusions larger than 20 mm in diameter had a worse histological grading than smaller ones.

Confluent, rather than diffuse, colonic contusions were more severe injuries.

Conclusion Once identified at laparotomy, the number of small bowel contusions requiring excision may be reduced from 86 to 60 per cent; similarly, excision of colonic contusions can be reduced from 73 to 27 per cent if small bowel contusions smaller than 15 mm in diameter and colonic contusions of less than 20 mm are managed conservatively

Delayed intestinal perforation after nonpenetrating abdominal trauma.Can J Surg. 1985 Sep;28(5):437-9Winton TL, Girotti MJ, Manley PN, Sterns EE.

The authors report 4 patients who suffered delayed intestinal perforation 6 or more days after sustaining nonpenetratingabdominal trauma in motor vehicle accidents while wearing passive seat-belt restraints.

All patients had low severity of injury (scores ranging from 4 to 13) but had persistent vague abdominal pain before perforation occurred.

3 of the 4 patients suffered spinal trauma as their major initial injury. Such patients appear to be at higher risk for delayed perforation and should be monitored carefully.

Delayed perforation of the colon in blunt abdominal trauma.Bubenik O, Meakins JL, McLean AP.Can J Surg. 1980 Sep;23(5):473-5.

The authors describe three patients with similar clinical features and patterns of colonic injury following blunt abdominal trauma. Perforation was discovered 7 to 10 days after injury and was indicated by the clinical signs of systemic sepsis.

A prominent sign of occult sepsis was post-traumatic pulmonary insufficiency.

Blunt trauma to the colon was initially present but was not very impressive, consequently diagnosis was delayed.

The large number of concomitant injuries and the subsequent sepsis led to a higher morbidity and mortality than in cases of penetrating injuries to the colon.

The key to successful management of blunt colonic injuries is early diagnosis. Awareness of the type of injury and the magnitude of the deceleration force combined with the presence of persistent ileus may lead to earlier laparotomy.

Delayed perforation of the sigmoid colon following closed abdominal trauma. Apropos of a case report

Acta Chir Belg. 1992 Jul-Aug;92(4):172-5. [Article in French]

Mourad M, Desrousseaux B, Atat I, Abizeid G, Lepoutre B, Ampe J.

Services de Chirurgie digestive et thoracique, Centre Hospitalier Saint Philibert, Lomme, France.

a case of delayed perforation of sigmoid colon, three days after a blunt abdominal trauma in a male adult. It was caused by disinsertion of sigmoid colon mesentery for about ten centimeters.

ConclusionDelay between injury and operation, extensive contamination, associated intra-abdominal injuries, and the presence of hemodynamic instability favor placement of a protective colostomy.

Mortality rates from blunt intestinal trauma range from 10% to 30%.

The mortality is most closely related to the number and severity of other injuries, not to the specific intestinal injury or its surgical management.

However, delay in diagnosis of a perforated colon increases themortality rate by 25% to 33%.

ConclusionCT scanning and selective Laparoscopy can prevent nontherapeutic laparotomy and delayed diagnosis in patients with suspected BBI.

A cell count ratio >/=1 predicted hollow organ perforation with a specificity of 97% and a sensitivity of 100%.

Ultrasonography and laparoscopy are additional diagnostic techniques available to the clinician, but both lack the sensitivity to aid in early diagnosis.

?Questions

ReferencesBugis SP, Blair NP, Letwin ER: Management of blunt and penetrating colon injuries. Am J Surg 1992; 163:547-550 Carrillo EH, Somberg LB, Ceballos CE, et al: Blunt traumatic injuries to the colon and rectum. J Am Coll Surg 1996; 183:548-552 Howell HS, Bartizal JF, Freeark RJ: Blunt trauma involving the colon and rectum. J Trauma 1976; 16:624-632 Dauterive AH, Flancbaum L, Cox EF: Blunt intestinal trauma. Ann Surg 1985; 201:198-203 Maull KI, Reath DB: Impact of early recognition on outcome in nonpenetrating wounds of the small bowel. South Med J 1984; 77:1075-1077 Fang JF, Chan RJ, Lin BC: Cell-count ratio: new criterion of diagnostic peritoneal lavage for detection of hollow organ perforation. J Trauma 1998; 45:540-544 Hegenbarth R, Rehagel HJ. Ultrasound findings in rupture of the colon after blunt abdominal trauma. Ultraschall in derMedizin 1995; 16:297-298[German].[Medline]Sherbourne CD, Shanmuganathan K, Mirvis SE, et al. Visceral injury without hemoperitoneum: a limitation of screening abdominal sonography for trauma. Emerg Radiol 1997; 4:349-354. Gruessner R, Mentges B, Duber C, Ruckert K, Rothmand M. Sonography versus peritoneal lavage in blunt abdominal trauma. J Trauma 1989; 29:242-244.[Medline]Goletti O, Ghiselli G, Lippolis PV. The role of ultrasonography in blunt abdominal trauma: results in 250 consecutive cases. J Trauma 1994; 36:178-181.[Medline]Knudson MM, McAninch JW, Gomez R, Lee P, Stubbs HA. Hematuria as a predictor of abdominal injury after blunt trauma. Am J Surg 1992; 164:482-485.[Medline]Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of abdominal injury in children after blunt trauma. Ann Surg 1988; 208:688-693.[Medline]Siniluoto TM, Paivansalo MJ, Lanning FP, Typpo AB, Lohela PK, Kotaniemi AE. Ultrasonography in traumatic splenicrupture. Clin Radiol 1992; 46:391-396.[Medline]

Donohue JH, Federle MP, Griffiths BG, Trunkey DD. Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries. J Trauma 1987; 27:11-17.[Medline]Levine CD, Gonzales RN, Wachsberg RH, Ghanekar D. CT findings of bowel and mesenteric injury. J Comput Assist Tomogr 1997; 21:974-979.[Medline]Breen DJ, Janzen DL, Zwirewich CV, Nagy AG. Blunt bowel and mesenteric injury: diagnostic performance of CT signs. J Comput Assist Tomogr 1997; 21:706-712.[Medline]Rizzo MJ, Federle MP, Griffiths BG. Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT. Radiology 1989; 173:143-148.[Abstract]Mirvis SE, Gens DR, Shanmuganathan K. Rupture of the bowel after blunt abdominal trauma: diagnosis with CT. AJR 1992; 159:1217-1223.[Abstract]Pearl WS, Todd KH. Ultrasonography for the initial evaluation of blunt abdominal trauma: a review of prospective trials. Ann Emerg Med 1996; 27:353-361.[Medline]McGahan JP, Rose J, Coates TL, Wisner DH, Newberry P. Use of ultrasonography in the patient with acute abdominal trauma. J Ultrasound Med 1997; 16:653-662.[Abstract]Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D, Aprahamian C. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma 1995; 38:879-885.[Medline]Porter RS, Nester BA, Dalsey WC, et al. Use of ultrasound to determine need for laparotomy in trauma patients. Ann Emerg Med 1997; 29:323-330.[Medline]Nordenholz KE, Rubin MA, Gularte GG, Liang HK. Ultrasound in the evaluation and management of blunt abdominal trauma. Ann Emerg Med 1997; 29:357-366.[Medline]Healey MA, Simons RK, Winchell RJ, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful?. J Trauma 1996; 40:875-883.[Medline]Rothlin MA, Naf R, Amgwerd M, et al. Ultrasound in blunt abdominal and thoracic trauma. J Trauma 1993; 34:488-495.[Medline]Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling. II. Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990; 30:1427-1429.[Medline]

Burney RE, Mueller GL, Coon GL, et al. Diagnosis of isolated small bowel injury following blunt abdominal trauma. Ann Emerg Med 1983; 12:71-74.[Medline]Robbs JV, Moore SW, Pillay SP. Blunt abdominal trauma with jejunal injury: a review. J Trauma 1980; 20:308-311.[Medline]Bloom AI, Rivkind A, Zamir G, et al. Blunt injury of the small intestine and mesentery: the trauma surgeon's Achilles heel?. Eur J Emerg Med 1996; 3:85-91.[Medline]Bensard DD, Beaver BL, Besner GE, Cooney DR. Small bowel injury in children after blunt abdominal trauma: is diagnostic delay important?. J Trauma 1996; 41:476-483.[Medline]Schimpl G, Schmidt B, Sauer H. Isolated bowel injury in blunt abdominal trauma in childhood. Eur J Pediatr Surg 1992; 2:341-344.[Medline]Fischer RP, Miller-Crotchett P, Reed RL. Gastrointestinal disruption: the hazard of nonoperative management in adults with blunt abdominal injury. J Trauma 1988; 28:1445-1449.[Medline]Phillips TF, Brotman S, Cleveland S, Cowley RA. Perforating injuries of the small bowel from blunt abdominal trauma. Ann Emerg Med 1983; 12:75-79.[Medline]Richards JR, Derlet RW. Computed tomography and blunt abdominal injury: patient selection based on examination, haematocrit and haematuria. Injury 1997; 28:181-185.[Medline]Moss RL, Musemeche CA. Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg 1996; 31:1178-1181.[Medline]Ryan JJ, Kyes FN, Horner WR, Young JC, Diamond DL. Critical analysis of open peritoneal lavage in blunt abdominal trauma. Am J Surg 1986; 15:221-223. Gomez GA, Alvarez R, Plasecia G, et al. Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment. J Trauma 1987; 27:1-5.[Medline]Kearney PA, Vahey T, Burney RE, Glazer G. Computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma: their combined role. Arch Surg 1989; 124:344-347.[Abstract]McKenney M, Lentz K, Nunez D, et al. Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma?. J Trauma 1994; 37:439-441.[Medline]Shah R, Max MH, Flint LM. Negative laparotomy: mortality and morbidity among 100 patients. Am Surg 1978; 44:150-154.[Medline]Peitzman AB, Makoroun MS, Slasky BS, Ritter P. Prospective study of computed tomography in initial management of blunt abdominal trauma. J Trauma 1986; 26:585-592.[Medline]Glazer GM, Buy JN, Mass AA, Goldberg HI, Federle MP. CT detection of duodenal perforation. AJR 1981; 137:333-336.[Medline]