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Isolated Cecal Rupture after Blunt Abdominal Trauma

Alemayehu Ginbo Bedada,1 Elijah Wade Riddle,2 Alemayehu Bekele Eshetu,3 Georges Azzie,4

  1. Department of Surgery, University of Botswana, Faculty of Medicine, Gaborone, Botswana

  2. Department of Surgery, University of Pennsylvania, Philadelphia, USA

  3. Department of Pathology, University of Botswana, Faculty of Medicine, Gaborone, Botswana

  4. Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto,Canada

Correspondence to: Dr. Alemayehu Bedada; email: bedale00@yahoo.co.uk

Summary

Cecal perforation following blunt abdominal trauma is an uncommon and challenging injury. We report a 19-year-old HIV-positive woman who presented with abdominal pain after a high-speed motor vehicle crash. Abdominal exam revealed a seatbelt sign with evidence of peritonitis; Focused Assessment with Sonography for Trauma showed free intraperitoneal fluid. After fluid resuscitation and antibiotics, the patient was taken for urgent laparotomy. Intraoperatively, we discovered hemoperitoneum and an isolated rupture of the cecum. A right hemicolectomy with end-to-end ileo-transverse colon anastomosis was performed. Her only significant postoperative complication was a superficial wound infection. We review the epidemiology of hollow viscus injury in blunt trauma and discuss important considerations in diagnosis and treatment.

 

Keywords: Blunt abdominal trauma, Cecal rupture, HIV positive, Hollow viscus

 

Ann Afr Surg. 2020; 17(3):134–136

DOI: http://dx.doi.org/10.4314/aas.v17i3.11

Conflicts of Interest: None

Funding: None

© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License

Submitted: 4 August 2019

Revised: 9 December 2019

Accepted: 28 January 2020

Online first: 29 May 2020

Introduction

Hollow viscus injury (HVI) following blunt trauma is challenging and uncommon, presenting in 0.3–9% of cases (1-7). HVI may involve serosal lacerations, mural hematomas, or ruptures following an acute rise in intra-luminal pressure (1-4,8). Reported rates of HVI following blunt trauma vary by organ: small bowel is affected in 55.0–80.9% (1-3,5), colon in 10.0–17.0% (1,5,8), duodenum in 10–12% (1,5), rectum in 7.0% (1), stomach in 3.0–4.3% (1,5), cecum in 0.57% (2), and appendix in 0.4% (5) of cases. HVI with perforation occurs in less than 1.0% of patients with blunt abdominal trauma (4,5,7).

Although compression of the intestine between the abdominal wall and the spine is considered the primary mechanism of injury (1,2,6-8), a combination of factors is probably involved. About 25% of patients who have surgery for presumed HVI have more than one site of bowel injury (2) and 21.4% have associated solid visceral injury (2). Seatbelts reduce mortality but are thought to increase HVI, particularly when worn incorrectly (6).

Abdominal pain and tenderness are common findings, but physical examination alone is not accurate in dictating the need for surgery (1,9). Associated injuries, administered pain medications, and alcohol or drug intoxication reduce the reliability of clinical examination (1,9). Bruising of the abdomen in the pattern of the seatbelt, the so-called “seatbelt sign,” is indicative of significant transfer of energy and highly associated with intra-abdominal injury (7), more so when free intra-abdominal fluid or fracture of thoracolumbar vertebrae is present (6).

No individual or combination of diagnostic tests, including physical examination, x-ray, ultrasound, and computed tomography (1,4,8), have been shown to accurately detect colonic injury (4). Certain CT findings including focal wall thickening, bowel wall hematoma, enteral contrast extravasation, discontinuity of bowel wall, foci of air near a hollow viscus, frank pneumoperitoneum, and intraperitoneal fluid suggest HVI (1,2,4,6,7).

Simple closure may be appropriate in the case of an isolated perforation with minimal contamination (2,10). Resection and anastomosis are required for some small and large bowel injuries (2,10). A proximal diverting stoma may be of value in intestinal injuries where the patient is toxic or moribund, or when a grossly contaminated peritoneum is present (2,10).

 

Case report

A 19-year-old girl presented with abdominal pain following a motor vehicle crash. She was a restrained backseat passenger in a car that struck a tree at high speed. The driver died and two other passengers sustained major head and abdominal injuries. On primary survey, her airway was intact and she communicated in full sentences. A cervical collar was placed. She was breathing comfortably at 16 breaths/min with bilateral breath sounds. Oxygen saturation was 100% on room air. She had a pulse rate of 101/min with blood pressure of 148/112 mmHg. Femoral and peripheral pulses were palpable with normal capillary refill. Two peripheral intravenous cannulas were placed, and fluids initiated after drawing blood for labs. Glasgow Coma Scale was 15 with no neurologic deficits. FAST showed free intraperitoneal fluid. Chest and pelvic radiographs were normal.

Secondary survey showed mild abdominal distension, seatbelt sign across the right lower abdomen, and tenderness to percussion with guarding. Lab results showed hemoglobin of 12.9 mg/dL, WBC of 3,370/µL, and platelet count of 101,000/µL.

The patient had been diagnosed with HIV 18 months before the accident and started on antiretroviral treatment, but had defaulted in the previous two months. At the time of presentation, her CD4 count was low at 465/µL, CD8 was 685/µL, and vir