REV ARGENT COLOPROCT | 2024 | VOL. 35, N

2 CASE REPORT

BURST OF HOLLOW VISCUS DUE TO BLUNT ABDOMINAL TRAUMA da Rosa Carneiro V., et al.

Case report: Burst of hollow viscus due to

blunt abdominal trauma

Valentina da Rosa Carneiro

, Javier Fender

, Pablo Ramade Francolino

, Raúl Perdomo Pereira

1 General Surgery Resident

2 General Surgeon

3 Clinical Assistant

Department of General Surgery, Hospital Escuela del Litoral, Paysandú. Uruguay

ABSTRACT

Intestinal injuries due to blunt abdominal trauma are rare, especially

in a sports environment. Delays in diagnosis are associated with

high morbidity and mortality. We present the case of a 23-year-old

male patient who attended to the emergency department due to

severe abdominal pain after blunt abdominal trauma secondary to

soccer practice. Abdominopelvic computed tomography showed

pneumoperitoneum and findings compatible with hollow viscus

injury. Emergency laparoscopy was performed, finding diffuse

peritonitis and tangential injury of the terminal ileum, that was

sutured with good results.

Key words: intestinal burst, blunt abdominal trauma, laparoscopy

INTRODUCTION

In blunt abdominal trauma, solid organ injuries are the most

common, unlike hollow viscera injuries. The latter are only

suspected when symptoms are suggestive.

In these traumas,

the intestine is the third most common viscera injured, with

an incidence that ranges between 3.1 and 5%, which in-

creases if other organs are injured.

These injuries are caused by three mechanisms: crushing

between the abdominal wall and the spine, tearing due to

sudden deceleration, and bursting as a consequence of

increased intraluminal pressure.

There are four small bowel injuries described by the Ameri-

can Association for Surgery and Trauma (AAST).

Grade I: Hematoma or contusion without devascularization,

or partial thickness tear without perforation.

Grade II: Laceration of less than 50% of the circumference.

Grade III: Laceration equal or greater than 50% of the

circumference, without transection.

Grade IV: Vascular laceration, intestinal transection, tran-

section with segmental loss of tissue or presence of a devas-

cularized segment.

From what has already been mentioned the diagnosis is not

always made early, which generates a delay in treatment

with an increase in the patient’s morbidity and mortality.

The present clinical case seeks to present our institutional

experience with a patient who presented intestinal burst

injury as a consequence of blunt abdominal trauma, with

laparoscopic surgical resolution with good results.

CASE

A 23-year-old male patient, with no personal history of note,

attended a rural clinic for severe right inguinal pain associ-

ated with the presence of a tumor at that level, one hour after

a blunt trauma during soccer practice. Since the patient was

hemodynamically stable and had no acute anemia, he was

given intravenous analgesia and discharged afterwards.

24 hours later he returned to the clinic due to severe diffuse

abdominal pain accompanied by anorexia, nausea, sporadic

bilious vomiting and intestinal transit arrest, for which he

was referred to the regional hospital.

The physical examination revealed a patient on good general

condition, lucid, dehydrated, hemodynamically stable, with

pain expressions in his face. Upon abdominal inspection,

there was evidence of trauma at the right iliac fossa (Fig. 1).

On palpation, abdomen was rigid, painful on superficial

palpation with diffuse rebound tenderness and absent bowel

sounds.

Figure 1. Patient in the operating room. Traces of trauma is ob-

served in the right iliac fossa.

Blood tests showed leukocytosis (15.000 cells/mm3 with

predominance of neutrophils), C-Reactive Protein 162.

Abdominopelvic computed tomography revealed mild

pneumoperitoneum and diffuse intra-abdominal free fluid

(Fig. 2). On the right flank there was heterogeneous density

in relation to the intestinal contents. Loops of small intestine

partially distended with air-fluid levels and inflammatory

thickening of the peritoneum were found. Findings were in

relation to rupture of hollow viscus.

Preoperative medical treatment was initiated with analge-

sics, empiric antibiotics and intravenous hydration. Urgent

laparoscopy was indicated (Fig. 3). Upon examination,

abundant enteral content with pseudomembranes was ob-

served in all peritoneal recesses associated with a large

hematoma in the mesentery. At the level of the last ileal

loop, a tangential lesion of approximately 0.5 cm was ob-

served. Extensive peritoneal cleansing was performed, the

injured intestine was sutured with PDS 4-0, and silicone

drainage was left in the pouch of Douglas.

The authors declare no conflict of interest. Valentina da Rosa Carneiro: valedarosa_13@hotmail.com

Valentina da Rosa Carneiro: https://orcid.org/0000-0002-0145-3015. Javier Fender: https://orcid.org/0009-0005-5652-6401, Pablo Ramade Francolino: https://orcid.org/0000-0001-5414-151X,

Raúl Perdomo Pereira: https://orcid.org/0000-0001-9463-9355

REV ARGENT COLOPROCT | 2024 | VOL. 35, N

2 CASE REPORT

BURST OF HOLLOW VISCUS DUE TO BLUNT ABDOMINAL TRAUMA da Rosa Carneiro V., et al.

Figure 2. CT scan. Axial section. A. Pneumoperitoneum (white

arrow) and perihepatic free fluid (black arrow) are visualized.

B. Free fluid (black arrows) and distended loops of small intestine

(red arrows).

Figure 3. A. Small intestine covered with pseudomembranes is

visualized. In the distal ileum, tangential lesion with enteral contents

(black arrow). B. Large hematoma of the mesentery (white arrow)

and loops of small intestine covered with pseudomembranes.

The patient had a good postoperative evolution, initiating

oral intake after 48 hours. He was walking by his own

means, without abdominal pain, with positive intestinal

transit and with low serohematic output drainage. After a

week, the drain was removed and the patient was dis-

charged.

He was monitored in the clinic one week and one month

after surgery. He had no further symptoms and he was

surgically discharged.

DISCUSSION

Small bowel injuries have a better prognosis than colon

injuries due to their lower bacterial load, better vasculariza-

tion and easier surgical management. However, they have a

worse prognosis when caused by blunt trauma than by

penetrating trauma due to a delay diagnosis and surgical

exploration.

Regarding the diagnosis, the physical examination will

present abdominal pain on palpation, signs of peritoneal

irritation and absent bowel sounds. These are signs suggest-

ing an acute abdomen, but not they are not sufficient to

determine the organ injured.

If hemodynamics are stable, contrast-enhanced computed

tomography is a priority. It provides information on possible

affected organs such as the spleen, liver or retroperitoneum,

it shows the presence of free fluid, as well as elements

suggestive of hollow viscus injury.

Regarding treatment, blunt trauma can be addressed by

laparoscopy. However, since the majority of patients are

polytraumatized and may present associated injuries, hemo-

dynamic instability, or brain trauma, laparotomy is usually

performed.

Laparoscopy is a valid option in hemodynami-

cally stable patients. The purpose of laparoscopy in trauma

is to avoid more than 20% of unnecessary laparotomies.

In minor intestinal injuries, primary closure is the appropri-

ate treatment but when there are ischemic segments, intesti-

nal resection is paramount.

One of the situations in which laparoscopy is very useful is

when CT visualizes free fluid without injury of solid organs

or pneumoperitoneum, since there may be an injury of the

mesentery or hollow viscus, both of which require immedi-

ate surgical resolution.

6,8

CONCLUSIONS

The advent of laparoscopic surgery in trauma in our envi-

ronment will allow us to avoid unnecessary laparotomies,

reduce hospital stay and associated morbidity, reduce costs

in medical care, providing timely and decisive treatment

with its undeniable benefits.

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