Paediatric case of a large gastric rupture after a blunt abdominal trauma: Report of a case in a District General Hospital

INTRODUCTIONIsolated gastric rupture after blunt abdominal trauma is rare. In current literature gastric rupture from blunt abdominal trauma ranges between 0.02% and 1.7%. This document reports the first non-motor-vehicle case of an isolated gastric rapture after blunt abdominal injury, which repaired after early diagnosis and aggressive surgical treatment.PRESENTATION OF CASEA 14-year-old boy attended our emergency surgical department after sustained a blunt abdominal trauma following a fall from his bicycle. He presented with pain and left para-umbilical abdominal ecchymoses. Examination revealed subcutaneous emphysema and a palpable abdominal wall dimple.DISCUSSIONRadiological examination with CT scan determined the need for exploratory laparotomy. Operation revealed, extensive rupture of the left lateral border of the rectus abdominus muscle, free intra-peritoneal position of the nasogastric tube with gross spillage of gastric contents and pneumo-peritoneum observed with 7-8cm full thickness rupture of anterior stomach wall, from the lesser towards the greater curvature. Primary, two-layer closure was performed. On the 5th post-operative day he developed gastrorrhagia. He was discharged on the 15th postoperative day.CONCLUSIONWe present this case report focusing on the paediatric patient to illustrate isolated gastric injury in terms of mechanism of injury, clinical presentation, and immediate surgical management.     

Characteristic features of abdominal organ injuries associated with gastric rupture in blunt abdominal trauma

BACKGROUND: Previous studies have investigated the mechanisms of gastric rupture based only on the findings in gastric rupture and excluding gastric lacerations. METHODS: We investigated 14 cases of gastric injury (five with rupture and nine with laceration) from blunt abdominal trauma with or without thoracic trauma. Gastric injuries were caused by a traffic accident in 12 and by a fall in two patients. All of the patients with gastric rupture had had a full stomach at the time of impact. RESULTS: The patients had associated injuries of adjacent solid organs, the thoracic cage, and extremities. The frequency of injury of the hepatoduodenal or gastrohepatic ligament was higher in patients with gastric laceration than in patients with gastric rupture. Eight of nine patients with a gastric laceration had hepatic or pancreatic injury, whereas none of the patients with gastric rupture had such injury. CONCLUSIONS: The results of our study showed that the distended stomach tends to rupture by absorbing the impact from blunt abdominal trauma (i.e., it works like an airbag to protecting adjacent organs such as the liver and pancreas).     

Gastric rupture from blunt abdominal trauma

Gastric rupture following blunt abdominal trauma is rare, with a reported incidence of 0.02-1.7%. Road traffic accidents remain the most frequent cause. The factors most often implicated in the genesis of this entity are: a history of a recent meal, trauma to the left side of the body and an inappropriate use of seat belts. Splenic injury is generally the most common associated injury. The high morbidity and mortality are directly related to the number of associated injuries, delays in diagnosis and the development of intraabdominal sepsis. We performed a retrospective study of 1300 patients with blunt trauma to the abdomen from 1973 to 2001. Seven patients sustained a gastric rupture (five men and two women). The following associated characteristics were analysed: mechanism of injury, clinical presentation, possible associated injuries and postoperative complications, diagnosis methods and surgical treatment. We found an incidence of gastric rupture of 0.5%. We emphasise an early diagnosis and aggressive surgical treatment as a key to decreasing the mortality and morbidity from this injury. However, in our series, the morbidity is mainly from associated injuries.     

间接暴力致肝门部放射状损伤

目的　探讨腹部闭合性损伤致肝门部放射状肝破裂的形成机制、临床特点及治疗特点。方法　回顾性总结了 1990年 8月～ 2 0 0 2年 9月间 8例闭合性腹部外伤致肝门部放射状肝破裂及合并伤的临床表现、治疗方法和结果。结果　 8例病人全部经手术治疗痊愈 ,对胆囊撕脱伤及胆管裂伤患者随访 2～ 3年 ,无不良反应。结论　肝门部放射状肝破裂由间接暴力所致 ,可伴有胆囊撕脱伤 ,肝门胆管、血管及第三肝门裂伤。主要表现为失血性休克 ,修补肝破裂的同时 ,注意合并伤的处理。     

创伤性肝胆管损伤的外科处理

目的探讨创伤性肝胆管损伤的处理方法。方法回顾性分析近10年我院收治220例肝创伤中12例肝胆管损伤患者的临床资料：结果除外院转入1例因来院过晚,失去手术时机衰竭死亡外,另11例均获痊愈：其中7例再手术治疗：1例持续胆漏予以近端漏口缝扎,胆总管引流;3例因反复发作化脓性胆管炎、梗阻性黄疸,行胆管空肠Roux—Y吻合术：另3例伴有肝萎缩、创伤性胆道出血分别行肝段、叶切除术。尚有4例胆漏维持通畅引流．亦获满意结果．于2周内停止胆漏。结论肝创伤合并肝胆管损伤,经初期和后期认真处理,均可获得良好预后．     

Intra-arterial thrombolysis in the carotid territory

Background: In patients who sustain abdominal trauma the liver is the most frequently injured organ. Although treatment for haemodynamically unstable patients remains urgent surgery, there has been a shift of management in haemodynamacally stable patients towards non-operative management. We performed an outcome assessment of traumatic hepatic injury.

Methods: A retrospective study was performed to assess incidence, mechanisms, management and outcome of traumatic liver injury in the region of ’s-Hertogenbosch, the Netherlands, in the period 1999–2007.

Results: A total of 47 patients were identified. Thirty-six patients had blunt hepatic trauma, eleven sustained penetrating hepatic injury. In 67% (n = 24) of the blunt hepatic trauma patients the initial intention was to treat non-operatively. Yet, two patients underwent explorative laparotomy after one and two days. In the penetrating liver trauma patients, 91% (n = 10) underwent urgent surgery. In total, 31 of 47 patients were treated conservatively.

Conclusion: Blunt hepatic trauma is the most common cause of hepatic trauma. Most patients sustaining hepatic trauma can be managed conservatively at a dedicated ICU and/or surgical trauma ward.     

Perforation of gastroesophageal junction,stomach, and diaphragm following blunt abdominal trauma: A near miss: A case report

IntroductionBlunt abdominal trauma causing Gastro-esophageal junction (GEJ), diaphragm, and gastric perforation in children is a very rare occurrence. However, the injury is serious and life-threatening with significant morbidity and mortality.Presentation of caseWe report an unusual case of a 14-year-old boy with an accidental fall from the tree with blunt abdomen trauma with a perforating injury to GEJ, stomach, and diaphragm.DiscussionMultiple vital organs in the abdominal cavity are vulnerable to damage in blunt abdominal trauma. The rarity of perforation, diagnostic delay, and early septic occurrence sums up to higher patient morbidity and mortality. A high degree of suspicion and urgent laparotomy and surgical repair forms the cornerstone in management.ConclusionEarly suspicion along with effective resuscitation and early laparotomy and surgical repair is crucial for survival and optimal outcome of the patient.     

Isolated Traumatic Gallbladder Rupture

Blunt traumatic injury to the extrahepatic biliary system is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon, but poses a potential life-threatening surgical emergency. Delay in the diagnosis of the injury for several days due to no or vague symptoms and an insidious course are common. Early diagnosis is essential, as protracted treatment may result in significant morbidity and mortality. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma from a fall. The subject of isolated traumatic gallbladder rupture is reviewed because of the rarity of this condition and the diagnostic challenges it poses.     

PATTERNS OF INJURY FROM MAJOR TRAUMA IN VICTORIA

Basic demographic and injury data were collected on all major trauma patients (ISS > 15) presenting to 25 Victorian hospitals over a 1 year period (March 1992-February 1993). A total of 1076 patients were identified with an Injury Severity Score (ISS) > 15. Of these, 957 resulted from blunt trauma, 68 from penetrating trauma and 51 from burns. Most serious blunt injury was transport-related (n= 652) but falls made up a significant proportion (n= 206). The pattern of injury in blunt trauma demonstrated in this study showed a preponderance of serious head, thoracic and limb injuries with less frequent occurrences of abdominal, spine and facial injuries. In major penetrating trauma, serious injuries of the thorax and abdomen were more frequent. Head injury is the most common cause of morbidity in major trauma patients. Motor vehicle accidents caused the majority of head injuries but, proportionately, head injury was more common in pedal cycle, pedestrian, motorcycle injuries and falls. The low frequency of major abdominal trauma has important implications for surgical training and resource allocation. In Victoria, various injury prevention interventions have been introduced such as compulsory wearing of bicycle helmets, a safer home environment and behavioural modifications through advertising. Injury prevention strategies must continue to target the populations at risk and assess the impact of interventions by accurate injury surveillance.     

Delayed intraperitoneal ureteric rupture following blunt abdominal trauma: case report

Ureteric injury is uncommon and mostly follows penetrating trauma or surgical injury. Ureteric rupture following blunt abdominal trauma is rare, there being only a few reported cases. The case described here, in which blunt abdominal trauma resulted in delayed intraperitoneal rupture, appears to be the first report of this type of injury in blunt trauma.     

The distinct and secondary harmful effect of pelvic and extremity injury on the outcome of laparotomy for trauma

HYPOTHESIS: Extra-abdominal injury negatively affects the outcome of abdominal injury following trauma laparotomy. DESIGN: Retrospective review of 920 consecutive patients receiving laparotomy for trauma who survived more than 24 h between January 1989 and May 1998 at a Level 1 trauma center. Major abdominal complications (MAC) were defined as: abdominal compartment syndrome (ACS), abscess/peritonitis, enterocutaneous fistula, necrotizing fasciitis, and necrotizing pancreatitis. METHODS: Univariant and multivariant logistic regression were used to identify predictors of MAC. RESULTS: Sixty-nine patients (7.5%) developed one or more MAC. Patients who developed MAC had higher injury severity scores (ISS), abdominal trauma indices (ATI), and blood transfusions in the first 24 h (PRCs) than patients who did not develop MAC. Patients with MAC were more likely to have suffered a thoracic or pelvic injury with an abbreviated injury scale (AIS) > or =3 and were more likely to have received an extremity injury (AIS > or =3) operation than patients without MAC. Independent predictors of MAC in multivariant analysis included colon injury (AIS > or =3) [odds ratio (OR) = 3.1, 95% confidence interval (CI) 1.5- 6.3)], pelvic injury (AIS > or =3) or operation for extremity injury (AIS > or =3) [OR 2.9, 95% CI 1.5-5.3], and ATI (OR = 1.03 for each 10 unit increase in ATI, 95% CI 1.02-1.05). PRCs did not independently predict MAC. CONCLUSION: The outcome of laparotomy for trauma (both blunt and penetrating) is negatively affected by a severe pelvic injury or a severe extremity injury operation independent of initial hemorrhage and abdominal injury severity.     

Blunt traumatic cardiac rupture: Therapeutic options and outcomes

Introduction

Cardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same.

Methods

This is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome.

Results

The study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18 ± 5.7 (range: 25-43), 6.267 ± 1.684 (range: 2.628-7.841), and 72.4 ± 25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n = 4), right atrial auricle (n = 1), right ventricle (n = 4), left ventricular contusion (n = 1), and diffuse endomyocardial dissection over the right and left ventricles (n = 1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state.

Conclusions

We proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.     

The Epidemiology of and Outcome from Pancreatoduodenal Trauma in the UK, 1989–2013

Introduction

Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989–2013.

Methods

The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both.

Results

Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14–35) for blunt trauma and 14 (IQR: 9–18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation.

Conclusions

Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.     

急诊床旁超声在腹部损伤中的应用价值

目的 了解急诊床旁超声在腹部闭合性损伤中的应用价值.方法 回顾性分析67例腹部闭合性创伤超声影像资料.结果 所有患者行急诊床旁超声检查,诊断符合率分别为:肝损伤92%,脾损伤93%,肾损伤80%,胰腺损伤50%,空腔脏器损伤67%,肠系膜血管损伤100%,腹膜后血肿100%.结论 急诊床旁超声是诊断腹部创伤致内脏破裂出...     

Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?

Background

Computerized tomography (CT) is considered as the imaging study of choice for blunt abdominal trauma in children. Nevertheless, recent investigations clearly indicate an increased risk of cancer in children exposed to radiation during abdominal spiral CT. Therefore, alternative strategies should be used for the diagnosis and surgical decision making in blunt abdominal trauma in children.

Methods

Retrospective analysis included all children with intraabdominal organ rupture after blunt abdominal trauma. Patients were diagnosed by a standardized emergency protocol that included primary clinical assessment and repeated ultrasound but not routine CT. Efficacy of abdominal ultrasound was evaluated in regard to safe diagnosis and appropriate surgical decision making.

Results

The study included 35 children with intraabdominal organ rupture diagnosed by ultrasound. One fifth (7/35) of the patients were polytraumatized, whereas 28 of 35 had an isolated blunt abdominal trauma. All patients underwent immediate ultrasound scanning of the abdomen and retroperitoneal space. Two patients were immediately operated because of hemodynamically instability. Four of 7 polytraumatized patients and 7 of 28 patients with isolated blunt abdominal trauma were additionally diagnosed by spiral CT. Only 1 patient underwent subsequent surgery because of the findings in the CT. Ultrasound was effective in more than 97% (34/35) of the patients for diagnosis and appropriate surgical decision making.

Conclusion

Ultrasound combined with clinical assessment presents an effective method for safe diagnosis and appropriate surgical decision making in pediatric blunt abdominal trauma. Selected cases with polytrauma and/or unequivocal findings in the ultrasound should undergo abdominal CT. Patients requiring abdominal CT should have an anticipated benefit that exceeds the radiation risk. The importance of repeated clinical assessment cannot be overstated.     

腹腔镜早期探查术在腹部钝性外伤继发肠损伤中的应用价值

目的探讨腹腔镜早期探查术应用于腹部钝性外伤继发肠损伤中的临床效果,提高其治疗效果。方法回顾性分析在本院住院治疗的腹部钝性外伤继发肠损伤早期实施腹腔镜探查术患者40例的临床资料,并与同期早期（受伤后开始手术不超过6小时）手术患者38例进行比较。结果两组患者一般资料、肠管损伤部位及程度比较,差异无统计学意义（P〉0.05）;两组患者死亡率均较低,差异无统计学意义（P〉0．05）,但是观察组患者住院时间、ICU监护时间、机械通气时间及并发症发生率均低于对照组,差异存在统计学意义（P〈0．05）。结论腹腔镜探查术是集诊断和治疗为一体的现代化外科微创技术,在技术和设备许可的情况下,正确把握适应征,可以使腹部钝性外伤继发肠损伤患者获得最佳的诊治效果。     

Laparoscopic cholecystectomy for isolated traumatic rupture of the gallbladder following blunt abdominal injury

Gallbladder rupture following blunt abdominal trauma is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon. Delay in the diagnosis of the injury for several days due to no, or vague, symptoms and an insidious course is common. Early diagnosis is essential, as protracted treatment may result in significant morbidity and mortality. We report the case of a patient who suffered isolated gallbladder rupture due to blunt abdominal trauma from a fall. We propose laparoscopic cholecystectomy as a safe and effective surgical treatment for this solitary injury.     

Isolated gallbladder rupture due to blunt abdominal trauma

Traumatic injury to the extrahepatic biliary system is rare and usually diagnosed at laparotomy when it is associated with other visceral injuries. Isolated gallbladder rupture due to blunt abdominal trauma is even rarer. The clinical presentation of gallbladder injury is variable, resulting in a delay in diagnosis and treatment. Awareness to the possibility of trauma to the extrahepatic biliary system enables early surgical intervention and eliminates the high morbidity associated with delated diagnosis. A 5 year old child with isolated gallbladder rupture caused by blunt abdominal trauma is presented.     

Isolated Pancreatic Transection Due to Blunt Abdominal Trauma: Report of Three Cases and Literature Review

Abstract Pancreatic injuries caused by blunt abdominal trauma are rare occurrences consisting a small percentage of all pancreas injuries. Due to difficulties in diagnosis evaluation and associated injuries, blunt pancreas traumas are severe clinical cases with high mortality rates. We would like to discuss three cases admitted to our hospital last year, and current literature on diagnosis, management and surgical approach of blunt pancreas injuries. The incidents resulted from a traffic accident, a parade horse stamping the groom and a football game, in which the latter patient unfortunately died. These cases illustrate the importance of careful diagnosis, interpretation of findings and therapy planning of the acutely injured patient suffering blunt pancreatic trauma.