Traumatic small bowel perforation

Case contributed by Dr Mohamed Saber

Presentation

Post road traffic accident abdominal pain

Patient Data

Age: 30 years
Gender: Male

Initial CT study (plain and IV contrast)

CT

Initial CT study shows intraperitoneal minute free gas foci i.e pneumoperitoneum, anteriorly at the umbilical level with associated minimal free fluid, concerning for traumatic bowel injury

Right iliac bone comminuted fracture

Follow up CT (oral contrast only) after 12 hours

CT

Follow up CT study reveals increased pneumoperitoneum and fluid collection

Intra-operative

Photo

Intraoperative, there was a small jejunal perforation about 100 cm from the DJ junction with intraperitoneal free fluid.

Annotated image

The red circles outline the minimal pneumoperitoneum in the initial CT study

The green circle outlines the significant pneumoperitoneum in the follow-up study

Case Discussion

Bowel and pancreatic injuries are occasionally missed in imaging studies of abdominal trauma despite their critical sequelae. This case is an example of how occasionally it is difficult to detect a bowel injury in a CT study. Here are some helpful tips:

  • assessment of parenchymatous organ injury should not distract attention from potential bowel and pancreatic injuries
  • a careful search for a pneumoperitoneum should be done
  • even a minimal amount of pneumoperitoneum could be significant and requiring immediate surgery or at least close imaging follow up
  • lung window is helpful in the detection of pneumoperitoneum
  • in isolated traumatic small bowel injuries, the patient is usually vitally stable and complaining from abdominal pain only with a very low clinical suspicious about his injury

Intraoperative image contribution by the surgeon Dr Adel Abdelwahed

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