Late small bowel obstruction after blunt abdominal trauma

Abstract

Blunt abdominal trauma with intraperitoneal injury usually presents acutely. On rare occasions, such patients can present later on with features of small bowel obstruction due to stricture formation. It is thought that such a delayed stricture is due to subclinical bowel perforation, localised gut ischaemia, or injury to the mesenteric vasculature. This case demonstrates the mesenteric vascular injury theory to be the cause of the bowel stricture. B lunt abdominal trauma producing intraperitoneal injury usually presents acutely, necessitating laparotomy for intestinal perforation or mesenteric vascular injury.1 In the absence of shock and peritonism, patients with blunt abdominal injury may be treated conservatively. On rare occasions, such patients can present later on with features of small bowel obstruction.2 3 Delays in presentation between the initial insult to the abdomen and the obstructive episode have been documented to be as long as 26 years in the European literature. 4The exact pathophysiology is unclear, with three possible causes cited-subclinical small bowel perforation, localised bowel ischaemia, and mesenteric vascular injury. 5 We report the case of a 22 year old man who presented with small bowel obstruction two years after blunt abdominal trauma. Laparotomy revealed distal ileal stenosis with vascular mesenteric injury. This case reinforces the mesenteric vascular injury theory as the cause of the bowel stricture. CASE REPORTA healthy 20 year old man presented to the General Hospital, Port-of-Spain, having been involved in a motor vehicle accident one hour beforehand. He was the driver of a car that smashed into the rear of a stationary vehicle at low velocity. He was wearing a lap and shoulder belt at the time.Though he sustained blunt abdominal injury, bruising or the seatbelt sign were not evident. He was found to be stable with minimal abdominal tenderness. He was observed for a 24 hour period and subsequently discharged.He was seen repeatedly in the outpatient clinic for vague colicky abdominal pains which he had not experienced before injury. No investigations were ordered. Two years after the initial injury he presented to the surgical service with vomiting and constipation. His abdomen was mildly tender and grossly distended with increased bowel sounds. Plain abdominal radiographs revealed small bowel distension involving the jejunum and ileum.A laparotomy was performed and a stricture of the terminal ileum was observed. The adjacent mesentery was scarred and the mesenteric arterial pulsations were impalpable (fig 1). On table Doppler assessment revealed reduced biphasic arterial impulses within this segment of mesentery.The stenosed segment of ileum was resected and an end to end anastomosis performed. The specimen was examined histologically, revealing mucosal ulceration of the gut and degenerative infiltration of the mesenteric vessels.The patient was discharged after an uneventful postoperative course, and has remained symptom-free after five years.

A Rare Cause of Ileus: Late Jejunal Stricture following Blunt Abdominal Trauma

“…Authors agree that feeding deficiency related to damaged mesentery is primary reason for stricture formation. [4][5][6] In the present case, macroscopic evaluation showed fibrotic thickening in the mesentery of the strictured segment. It was suggested that the damage to the mesentery was the principal reason for the patient's condition as pathological analysis revealed focal ulcerated area and active chronic nonspecific inflammation in the area.…”

Full-Thickness Isolated Small Intestine Injury Due to Blunt Trauma

“…Although small bowel injury is the third most common type of injury after thoracic and heart injuries in blunt abdominal traumas, small bowel injury is seen in less than 1% of patients with blunt trauma. Among these patients, only 0.3% patients demonstrate small bowel perforation (1)(2)(3)6). Traffic accidents are the cause in 60%-80% of small bowel injuries associated with blunt trauma.…”

“…The patient received emergency surgery. Laparotomy revealed a full-thickness isolated ileal perforation 180 cm distal to the Treitz ligament and 300 mm 3 of bowel content in the abdomen. Necrotic tissues were resected, and end-to-end anastomosis was performed.…”

“…The proximal jejunum and terminal ileum are the most commonly injured parts of these hollow organs. Isolated bowel injuries are very rare and often present with accompanying organ injuries (1)(2)(3).…”

Double ischemic ileal stenosis secondary to mesenteric injury after blunt abdominal trauma

“…Three possible causes have been suggested: small bowel perforation [5] , localized bowel ischemia [1,4] and mesenteric injury [6] . Mesenteric vascular injury may induce chronic ischemia of the corresponding segment of small bowel, inducing secondary thickening of the bowel wall and intestinal occlusion [1,6] . Post-traumatic bowel lesions may also be found in the colon, mainly on the left www.wjgnet.com side, specifically the sigmoid colon [7] .…”