Ileal Perforation in a Patient with High Spinal Cord Injury: Report of a Case

Abstract

Assessing abdominal complications in patients who have previously suffered high spinal cord injury is very difficult because the resultant loss of sensory, motor, and reflux function of the abdominal wall can mask the typical signs of acute abdomen such as tenderness, muscle rigidity, and peritoneal rebound pain. We recently diagnosed a small intestinal perforation in a 77-year-old man with a C6-7 spinal cord injury sustained 14 years earlier. The patient was correctly diagnosed as having an acute abdominal condition, despite palsy of abdominal wall sensation. An emergency laparotomy was done and a 40-cm length of affected ileum, about 180 cm distal to the Treitz ligament, including a 1-cm perforation, was resected, followed by an end-to-end anastomosis. We report this case to raise awareness of the need for appropriate diagnosis and early surgical treatment of abdominal complications in spinal-cord-injured patients.

A silent acute abdomen in a patient with spinal cord injury

“…Diagnostic difficulties exist in SCI owing to the lack of display of normal clinical signs and symptoms associated with acute abdomen. As in this patient, there have been reports where abdominal pain/tenderness is completely absent 6 8 9. Signs of fever and leukocytosis are surprisingly infrequent 2 4…”

“…The literature describes cases where pain is in fact a presenting feature which could be well localised3–5 or vaguely localised presenting as a ‘sense’ of discomfort 3–6 8. Pain of an acute abdomen with low cord lesions is better localised and similar to normal patients3–5 whereas pain is more likely to be absent/vague in high cord lesions 4 5.…”

“…Other features that may be seen in the spectrum of acute abdomen include: loss of bowel sounds,3 abdominal distension,2 5 6 8 9 nausea/vomiting4 6 8 9 and increased abdominal spasticity 2–5. Spasticity is the result of intact spinal reflexes below the level of cord injury.…”

Paraplegic and quadriplegic patients undergoing emergency abdominal surgery

“…In PARA and QUAD patients, ''lower GIT'' surgical emergencies were, by far, the most common indication for operation in contrast to appendiceal operations, which were the most commonly performed procedure in the nonparaplegic/nonquadriplegic population, even after matching for age and sex. 6 Adjusted for attending operating surgeon, HBP surgery, and ASA score. For example, appendicitis left untreated may progress and ultimately require a more extensive exploration or resection Adjusted for appendectomy, upper GIT surgery, lower GIT surgery, ASA score, age, and BMI.…”

Intraabdominal Injury is Common in Blunt Trauma Patients who Sustain Spinal Cord Injury

“…T HE DIFFICULTY IN ASSESSING the abdomen in patients with spinal cord injury (SCI) has been well documented. [1][2][3][4] Patients with complete SCI above the T7 level have been shown to lose sensory, motor, and reflex functions of the abdominal wall. 1 The net result is an unreliable physical examination that can complicate the diagnosis of abdominal trauma.…”