1
|
Arslan S, Okur MH, Arslan MS, Aydogdu B, Zeytun H, Basuguy E, Icer M, Goya C. Management of gastrointestinal perforation from blunt and penetrating abdominal trauma in children: analysis of 96 patients. Pediatr Surg Int 2016; 32:1067-1073. [PMID: 27666540 DOI: 10.1007/s00383-016-3963-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 11/26/2022]
Abstract
AIM The objective of the present study was to evaluate the diagnostic methods, concomitant organ injuries, factors affecting mortality and morbidity, treatment methods, and outcomes of patients treated for traumatic gastrointestinal (GI) perforation. MATERIALS AND METHODS We conducted a retrospective review of the medical records of 96 patients who had been treated for GI perforation between January 2000 and October 2015. Data were collected and organised according to the following categories: general patient information, age, gender, hospitalisation period, trauma mechanisms, concomitant injuries, radiological assessment, diagnosis and treatment methods, treatment forms, and complications. The cases were divided into two groups, blunt and penetrating traumas, and the patients within each group were compared. Colorectal trauma cases were not included in this study. Patients suspected of a GI perforation were assessed by standing plain abdominal radiograph (SPAR) and ultrasound scan (US). Patients who had a normal SPAR, and showed free or viscous fluid in the abdomen on US underwent computed tomography (CT) scanning. Surgery was performed if patients displayed free air in the abdomen on a SPAR or CT scan, showed viscous fluid without any additional injury, provided normal radiological images but displayed signs of peritonitis, or were clinically unstable. The patients were scored according to the Injury Severity Score (ISS) system. RESULTS In total, 96 patients, with an average age of 10.3 ± 4 years (1-17 years) and diagnosed with a GI perforation, were reviewed retrospectively. The patients included 88 (91 %) males and 8 (9 %) females. The presence of free air on SPAR was detected in 42 (52 %) patients, whereas no free air was detected in 39 (48 %) patients. Non-specific significant findings were detected in 45 (76 %) out of 59 patients by USS, and in 78 % of patients by CT (viscous fluid, fluid, free air). The most affected organ was the ileum, which was detected in 37 (39 %) patients. Primary repair was performed on 71 (74 %) patients, while resection was performed on 22 (23 %); 3 (3 %) patients underwent an ostomy. Ten (10 %) patients experienced complications and five (5 %) patients died. The ISS scores for blunt and penetrating traumas were 14, 15 and no significant difference was detected between the scores (p > 0.05). CONCLUSIONS Although the complication rate for patients with penetrating trauma was higher than for those with blunt trauma, the rate of mortality increased in patients with blunt trauma. Free air may not be detected by SPAR even if a GI perforation exists. Since diagnostic challenges may increase the rate of mortality and morbidity in GI perforations, we believe that a combination of radiological imaging and rapid abdominal examination is important in cases where SPAR cannot detect free air.
Collapse
Affiliation(s)
- Serkan Arslan
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey.
- Dicle Üniversitesi Tıp Fakültesi, Çocuk Cerrahi A.D., Diyarbakır, Turkey.
| | - Mehmet Hanifi Okur
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Mehmet Serif Arslan
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Bahattin Aydogdu
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Hikmet Zeytun
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Erol Basuguy
- Department of Pediatric Surgery, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Mustafa Icer
- Department of Emergency Medicine, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| | - Cemil Goya
- Department of Radiology, Medical Faculty of Dicle University, Diyarbakir, AZ, 21000, Turkey
| |
Collapse
|
2
|
Vane DW, Keller MS, Sartorelli KH, Miceli AP. Pediatric Trauma: Current Concepts and Treatments. J Intensive Care Med 2016. [DOI: 10.1177/088506602237107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Injured children represent a complex management problem for the trauma surgeon. Physiologic and psychological factors have been shown to influence outcome; however, more importantly, injury patterns and treatment algorithms differ from those recommended for adults. Children often do well after major injuries, but surgeons must use appropriate treatment to maximize the physiologic responses and the innate healing abilities of the growing child. Historically, surgeons have defined childhood as prepubertal, but a child's physiologic response to injury extends well into the third decade of life, making treatment of a 20-year-old similar to that of a 10-year-old, rather than that of a 40-year-old. The distribution of pediatric trauma facilities across the country has limited the access of the injured child to these centers. Adult centers more often serve as the first and definitive treatment provider for children. This article reviews the current concepts of trauma treatments for children. It is hoped that the adult trauma surgeons caring for injured children might gain information that will be of assistance in their daily practice.
Collapse
Affiliation(s)
- Dennis W. Vane
- Division of Pediatric Surgery, University of Vermont College of Medicine, Burlington, VT,
| | | | - Kennith H. Sartorelli
- Division of Pediatric Surgery, University of Vermont College of Medicine, Burlington, VT
| | | |
Collapse
|
3
|
Miele V, Piccolo CL, Trinci M, Galluzzo M, Ianniello S, Brunese L. Diagnostic imaging of blunt abdominal trauma in pediatric patients. Radiol Med 2016; 121:409-30. [PMID: 27075018 DOI: 10.1007/s11547-016-0637-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 04/01/2016] [Indexed: 01/27/2023]
Abstract
Trauma is a leading cause of morbidity and mortality in childhood, and blunt trauma accounts for 80-90 % of abdominal injuries. The mechanism of trauma is quite similar to that of the adults, but there are important physiologic differences between children and adults in this field, such as the smaller blood vessels and the high vasoconstrictive response, leading to the spreading of a non-operative management. The early imaging of children undergoing a low-energy trauma can be performed by CEUS, a valuable diagnostic tool to demonstrate solid organ injuries with almost the same sensitivity of CT scans; nevertheless, as for as urinary tract injuries, MDCT remains still the technique of choice, because of its high sensitivity and accuracy, helping to discriminate between an intra-peritoneal form a retroperitoneal urinary leakage, requiring two different managements. The liver is the most common organ injured in blunt abdominal trauma followed by the spleen. Renal, pancreatic, and bowel injuries are quite rare. In this review we present various imaging findings of blunt abdominal trauma in children.
Collapse
Affiliation(s)
- Vittorio Miele
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Claudia Lucia Piccolo
- Department of Medicine and Health Sciences, Università del Molise, Campobasso, Italy
| | - Margherita Trinci
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Michele Galluzzo
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Stefania Ianniello
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences, Università del Molise, Campobasso, Italy
| |
Collapse
|
4
|
Fischerauer EE, Zötsch S, Capito C, Bonnard A, Sárközy S, Berndt J, Hosie S, Beltra Pico R, Steinau G, Wiejek A, Czauderna P, Çelik A, Lain Fernandez A, Ibanez VM, Esposito C, Saxena AK. Paediatric and adolescent traumatic gastrointestinal injuries: results of a European multicentre analysis. Acta Paediatr 2013; 102:977-81. [PMID: 23815746 DOI: 10.1111/apa.12337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 06/18/2013] [Accepted: 06/26/2013] [Indexed: 11/28/2022]
Abstract
AIM Paediatric gastrointestinal injuries (GIIs) are rare, and the aim of this multicentre study was to evaluate their outcomes in a large cohort. METHODS Hospital databases of 10 European paediatric surgical centres were reviewed for paediatric traumatic GIIs managed between 2000-2010. RESULTS Ninety-seven patients with a median age of 9 years (0-17 years) were identified, with 72 blunt and 25 penetrating GIIs. Initial diagnostics in 90 patients led to correct diagnosis in 71%. Diagnostics were delayed in 26 patients (median 24 h). Eighty-two patients required surgery (67 laparotomy, 12 laparoscopy and three other approaches). There was a 50% conversion in the laparoscopic group. Median hospital stay was 10 days (range 1-137 days), with longer duration influenced by associated injuries (n = 41). Diagnosis <24 h was associated with significantly shorter hospital stay compared to more than 24 h (p = 0.011). In one-third of patients, morbidities were not related to a diagnostic delay or type of injury. There were five lethal outcomes, four due to associated injuries. CONCLUSION Initial diagnostics in traumatic paediatric GIIs provide false negatives in one-third of patients. Diagnostic delay <24 h is associated with a significantly shorter hospital stay. Although laparoscopy is associated with a conversion rate of 50%, it can be used for diagnosis in suspected cases to avoid nontherapeutic laparotomy.
Collapse
Affiliation(s)
- EE Fischerauer
- Department of Pediatric- and Adolescent Surgery; Medical University of Graz; Graz; Austria
| | - S Zötsch
- Department of Pediatric- and Adolescent Surgery; Medical University of Graz; Graz; Austria
| | - C Capito
- General Pediatric Surgery; Robert Debre Hospital and Paris VII Denis Diderot University; Paris; France
| | - A Bonnard
- General Pediatric Surgery; Robert Debre Hospital and Paris VII Denis Diderot University; Paris; France
| | - S Sárközy
- Surgical Department; Heim Pál Children's Hospital; Budapest; Hungary
| | - J Berndt
- Department of Pediatric Surgery; München Schwabing, Munich; Germany
| | - S Hosie
- Department of Pediatric Surgery; München Schwabing, Munich; Germany
| | - R Beltra Pico
- Pediatric Surgery Unit; Hospital Univsersitario Materno-Infantil de Canarias; Las Palmas de Gran Canaria; Spain
| | - G Steinau
- Department of Surgery; University Hospital Aachen; Aachen; Germany
| | - A Wiejek
- Department of Surgery and Urology for Children and Adolescents; Medical University of Gdansk; Gdansk; Poland
| | - P Czauderna
- Department of Surgery and Urology for Children and Adolescents; Medical University of Gdansk; Gdansk; Poland
| | - A Çelik
- Department of Pediatric Surgery; Ege University Faculty of Medicine; Izmir; Turkey
| | - A Lain Fernandez
- Pediatric Surgery Department; Hospital Universitari Vall d'Hebron; Barcelona; Spain
| | - VM Ibanez
- Pediatric Surgery Department; Hospital Universitari Vall d'Hebron; Barcelona; Spain
| | - C Esposito
- Department of Pediatric Surgery; “Federico II” University of Naples; School of Medicine; Naples; Italy
| | - AK Saxena
- Department of Pediatric- and Adolescent Surgery; Medical University of Graz; Graz; Austria
| |
Collapse
|
5
|
Abstract
OBJECTIVE Trauma is a leading cause of morbidity and mortality in children. The abdomen is the second most common site of injury. This article discusses abdominal trauma in children. CONCLUSION The clinical evaluation of children with potential blunt abdominal injury presents a challenging task. Therefore, imaging plays an essential role in the evaluation of such children.
Collapse
|
6
|
Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol 2008; 43:72-82. [PMID: 18053830 DOI: 10.1053/j.ro.2007.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Sarah D Bixby
- Department of Radiology, Children's Hospital Boston, Boston, Massachusetts 02115,
| | | | | |
Collapse
|
7
|
Abbas SM, Upadhyay V. Hollow viscus injury in children: Starship Hospital experience. World J Emerg Surg 2007; 2:14. [PMID: 17547770 PMCID: PMC1892548 DOI: 10.1186/1749-7922-2-14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Accepted: 06/04/2007] [Indexed: 11/25/2022] Open
Abstract
Starship Children's Hospital in Auckland, New Zealand, serves a population of 1.2 million people and is a tertiary institution for pediatric trauma. This study is designed to review all cases of abdominal injury (blunt and penetrating) that resulted in injury of a hollow abdominal viscus including the stomach, duodenum, small intestine, large intestine and urinary bladder. The mechanism of injury; diagnosis and outcome were studied. This was done by retrospective chart review of patients admitted from January 1995 to December 2001. Thirty two injuries were found in 29 children. The age ranged from 7 months to 15 years with boys represented more commonly. Small bowel was the most frequently injured hollow viscus. Computerized Tomography (CT scan) is an extremely useful tool for the diagnosis of HVI.
Collapse
Affiliation(s)
- Saleh M Abbas
- University of Auckland; Starship Children's Hospital, Auckland, New Zealand
| | - Vipul Upadhyay
- University of Auckland; Starship Children's Hospital, Auckland, New Zealand
| |
Collapse
|
8
|
Affiliation(s)
- A Luana Stanescu
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | | | | | | |
Collapse
|
9
|
|
10
|
Brody JM, Leighton DB, Murphy BL, Abbott GF, Vaccaro JP, Jagminas L, Cioffi WG. CT of blunt trauma bowel and mesenteric injury: typical findings and pitfalls in diagnosis. Radiographics 2000; 20:1525-36; discussion 1536-7. [PMID: 11112806 DOI: 10.1148/radiographics.20.6.g00nv021525] [Citation(s) in RCA: 141] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Detection of bowel and mesenteric injury can be challenging in patients after blunt abdominal trauma. Early diagnosis and treatment are critical to decrease patient morbidity and mortality. Computed tomography (CT) has become the primary modality for the imaging of these patients. Signs of bowel perforation such as free air and contrast material are virtually pathognomonic. Bowel-wall thickening, free fluid, and mesenteric infiltration may be seen with this type of injury and partial thickness injuries. The authors present and discuss the range of CT findings seen with bowel and mesenteric injuries. Examples of observation and interpretation errors are also provided to highlight pitfalls encountered in the evaluation of abdominopelvic CT scans in patients after blunt trauma.
Collapse
Affiliation(s)
- J M Brody
- Departments of Diagnostic Imaging, Brown University School of Medicine, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903, USA.
| | | | | | | | | | | | | |
Collapse
|
11
|
Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management. Pediatr Emerg Care 2000; 16:189-95. [PMID: 10888461 DOI: 10.1097/00006565-200006000-00015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Evaluation of children with suspected abdominal trauma could be a difficult task. Unique anatomic and physiologic features render vital sign assessment and the physical examination less useful than in the adult population. Awareness of injury patterns and associations will improve the early diagnosis of abdominal trauma. Clinicians must have a complete understanding of common and atypical presentations of children with significant abdominal injuries. Knowledge of the utility and limitations of available laboratory and radiologic adjuncts will assist in accurately identifying abdominal injury. While other obvious injuries (eg, facial, cranial, and extremity trauma) can distract physicians from less obvious abdominal trauma, an algorithmic approach to evaluating and managing children with multisystem trauma will improve overall care and help to identify and treat abdominal injuries in a timely fashion. Finally, physicians must be aware of the capabilities of their own facility to handle pediatric trauma. Protocols must be in place for expediting the transfer of children who require a higher level of care. Knowledge of each of these areas will help to improve the overall care and outcome of children with abdominal trauma.
Collapse
Affiliation(s)
- S G Rothrock
- Department of Emergency Medicine, Orlando Regional Medical Center, Arnold Palmer Hospital for Children and Women, FL 37292, USA
| | | | | |
Collapse
|
12
|
Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part I: injury patterns and initial assessment. Pediatr Emerg Care 2000; 16:106-15. [PMID: 10784214 DOI: 10.1097/00006565-200004000-00012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Evaluation of children with abdominal trauma can be a difficult process. Unique anatomic features predispose children to specific injuries and potentially make identification of life-threatening injuries difficult. While Part I of this review discusses the initial assessment and diagnostic testing in children with abdominal trauma, Part II will review specific injuries and ED management of children with possible abdominal trauma. Knowledge of each of these factors will improve the ability of general and pediatric emergency physicians to expeditiously identify children with potential serious injury and initiate appropriate treatment.
Collapse
Affiliation(s)
- S G Rothrock
- Department of Emergency Medicine, Orlando Regional Medical Center, FL 32792, USA
| | | | | |
Collapse
|
13
|
Chang YS, Wang HP, Huang GT, Chen SC, Wang SM. Sonographic detection of delayed small bowel perforations after blunt abdominal trauma. JOURNAL OF CLINICAL ULTRASOUND : JCU 2000; 28:142-145. [PMID: 10679702 DOI: 10.1002/(sici)1097-0096(200003/04)28:3<142::aid-jcu7>3.0.co;2-f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Isolated perforations of the small bowel resulting from blunt abdominal trauma are rare and difficult to diagnose because of their variable presentation, especially when their appearance is delayed. We report 2 such cases that were diagnosed by sonography and emphasize the usefulness of sonography in detecting bowel injuries after blunt abdominal trauma.
Collapse
Affiliation(s)
- Y S Chang
- Department of Internal Medicine, Lee's General Hospital, Tachia Town, Taichung County, Taiwan
| | | | | | | | | |
Collapse
|
14
|
Maini A, Patel C, Agarwala S, Kumar A, Dasan B. Pediatric duodenal perforation demonstrated by hepatobiliary imaging. Clin Nucl Med 2000; 25:41-3. [PMID: 10634529 DOI: 10.1097/00003072-200001000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The diagnosis of intestinal perforation in children is difficult. Computed tomography has been a useful investigative modality. A case of duodenal perforation is presented in which radionuclide hepatobiliary imaging was useful.
Collapse
Affiliation(s)
- A Maini
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
| | | | | | | | | |
Collapse
|
15
|
Abstract
Although most traumatic abdominal injuries in children are treated with conservative nonsurgical management, traumatic perforation or infarction of the gastrointestinal tract still necessitates surgical management. It is imperative to recognize the often subtle computed tomographic (CT) findings of bowel or mesenteric trauma in children. Pediatric patients with bowel perforation or infarction due to trauma usually demonstrate multiple abnormalities at CT. A specific history of lap belt injury, bicycle handlebar injury, or child abuse with an abdominal injury should heighten suspicion for a bowel injury. CT findings in children with bowel or mesenteric trauma include free intraperitoneal air, free retroperitoneal air, extraluminal oral contrast material, free intraperitoneal fluid, bowel wall defect, bowel wall thickening, mesenteric stranding, fluid at the mesenteric root, focal hematoma, active hemorrhage, and mesenteric pseudoaneurysm. Some findings, such as free intraperitoneal air and focal bowel wall thickening, are associated with a strong likelihood of a bowel injury that requires surgical repair. Other findings, such as free intraperitoneal fluid, mesenteric stranding, fluid at the mesenteric root, and focal hematoma, are less specific for an injury that requires surgical repair. The hypoperfusion complex can usually be differentiated from a traumatic bowel injury; however, in some patients the imaging findings overlap.
Collapse
Affiliation(s)
- P J Strouse
- Department of Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor 48109-0252, USA
| | | | | | | |
Collapse
|
16
|
Abstract
Child abuse has been documented in various forms since the beginning of recorded history. This article reviews the legal aspects of reporting child abuse, the epidemiology of child abuse, various physical manifestations of child abuse, and effective treatment procedures. It is only with the appropriate interventions that physicians can begin to make an impact on the future of abused children.
Collapse
Affiliation(s)
- A M Jain
- Department of Emergency Medicine, George Washington University, Washington, DC, USA
| |
Collapse
|
17
|
Shankar KR, Lloyd DA, Kitteringham L, Carty HM. Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children. Br J Surg 1999; 86:1073-7. [PMID: 10460648 DOI: 10.1046/j.1365-2168.1999.01192.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of oral contrast in evaluating children by computed tomography (CT) following blunt trauma is controversial. The aim of this study was to evaluate retrospectively the use of oral contrast with abdominal CT in children with suspected abdominal injury. METHODS The medical records of 101 children who underwent CT for abdominal trauma between 1993 and 1997 were reviewed for data pertaining to the mechanism of injury, clinical findings and management. Scans were reviewed by a paediatric radiologist and criteria of intestinal injury on CT described by Cox and Kuhn were used: (1) extraluminal air or contrast material, (2) focal area of thickening of bowel wall and mesentery, and (3) free intraperitoneal fluid in the absence of solid organ injury. RESULTS CT was performed within a median time of 2.4 (range 1-48) h after the injury. On 37 (62 per cent) of 60 scans in children who had oral contrast, the duodenum was not opacified after a mean delay of 30 min. Intestinal injury was suspected on CT in four children. In two children with CT evidence of intestinal injury (with/without oral contrast) rupture of the duodenojejunal flexure (n = 1) or ileal perforation (n = 1) was found at laparotomy. Two children had a false-positive scan, leading to negative laparotomy; one scan with oral contrast incorrectly suggested a duodenal leak and in another child CT without oral contrast showed thickening of bowel wall with free intraperitoneal fluid but no specific intestinal injury was identified at laparotomy. One patient had two negative CT scans (with and without oral contrast) and underwent laparotomy for clinical suspicion of bowel injury; rupture of the splenic flexure of the colon was found at laparotomy. CONCLUSION CT is not reliable for diagnosing intestinal injuries and this is not improved by use of oral contrast. Omission of oral contrast was not associated with delay in the diagnosis of intestinal injury. Since intestinal injuries are uncommon in children, a prospective multicentre study would determine more precisely the role of the routine use of oral contrast.
Collapse
Affiliation(s)
- K R Shankar
- Department of Paediatric Surgery, Paediatric Radiology, Alder Hey Children's Hospital, Liverpool, UK
| | | | | | | |
Collapse
|
18
|
Canty TG, Canty TG, Brown C. Injuries of the gastrointestinal tract from blunt trauma in children: a 12-year experience at a designated pediatric trauma center. THE JOURNAL OF TRAUMA 1999; 46:234-40. [PMID: 10029026 DOI: 10.1097/00005373-199902000-00005] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Nonoperative management of solid organ injury from blunt trauma in children has focused concern on potential delays in diagnosis of hollow viscus injury with resultant increases in morbidity, mortality, and cost. This study of a large pediatric trauma database will review the issues of difficulty and/or delay in diagnosis as it relates specifically to definitive treatment and outcome. METHODS We surveyed 11,592 consecutive admissions to a designated pediatric trauma center from 1985 to 1997 to identify children with documented injury of the gastrointestinal (GI) tract from blunt trauma. The records were extensively analyzed specifically in regard to mechanism of injury, type and site of injury, time to diagnosis, operative treatment, complications, and final outcome. RESULTS The 79 children identified, 4 months to 17 years old, included 27 females and 52 males. Mechanism of injury included 15 restrained and 7 unrestrained passengers, 15 pedestrians, 15 child abuse victims, 10 bike handlebar intrusions, 8 discrete blows to the abdomen, 4 bike versus auto, 3 falls, and 2 crush injuries. There were 51 perforations, 6 avulsions, and 22 lesser injuries including contusions. Injury of the small bowel was most common, 44 cases, followed by the duodenum, 18 cases, colon, 17 cases, and stomach, 6 cases. In 45 children, diagnosis was made quickly by a combination of obvious clinical findings, plain x-ray and/or initial computed tomographic findings mandating urgent operative intervention. Diagnosis was delayed beyond 4 hours in 34 children, beyond 24 hours in 17 children and was made by persistent clinical suspicion, aided by delayed computed tomographic findings of bowel wall edema or unexplained fluid. The six deaths were caused by severe head injury. Complications included two delayed abscesses and two cases of intestinal obstruction. All 73 survivors left the hospital with normal bowel function. CONCLUSIONS Injury to the GI tract from blunt trauma in children is uncommon (<1%). The majority of GI tract injuries (60%) are caused by a discrete point of energy transfer such as a seatbelt (19%), a handle bar (13%), or a blow from abuse (19%), or other blows and is unique to this population. Although diagnosis may be difficult and often delayed, this did not result in excessive morbidity or mortality. Safe and effective treatment of GI tract injuries is compatible with nonoperative management of most other injuries associated with blunt abdominal trauma in children, while reducing the risk of nontherapeutic laparotomy.
Collapse
Affiliation(s)
- T G Canty
- Division of Trauma, Children's Hospital, San Diego, California, USA
| | | | | |
Collapse
|
19
|
Affiliation(s)
- P Rao
- Department of Radiology, Royal Liverpool Children's NHS Trust, Alder Hey, UK
| | | |
Collapse
|
20
|
Hulka F, Mullins RJ, Leonardo V, Harrison MW, Silberberg P. Significance of peritoneal fluid as an isolated finding on abdominal computed tomographic scans in pediatric trauma patients. THE JOURNAL OF TRAUMA 1998; 44:1069-72. [PMID: 9637164 DOI: 10.1097/00005373-199806000-00021] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peritoneal fluid on abdominal computed tomographic (CT) scan in the absence of solid-organ injury suggests a bowel injury. We sought to determine the significance of peritoneal fluid as the sole finding on abdominal CT scans obtained to evaluate injured pediatric patients. METHODS We performed a retrospective review of abdominal CT scans obtained during the initial survey of blunt trauma patients less than 19 years old during a 5-year period (1991-1995). All patients received intravenous and oral contrast agents. All CT scans were read by a staff radiologist. All CT scan results were retrospectively verified by one of the authors. RESULTS Of the 259 scans, 157 (59%) were read as normal; 76 (31%) demonstrated solid-organ injury or pelvic fracture; 2 (1%) had pneumoperitoneum and 24 (9%) had peritoneal fluid as the only finding. Quantification of the fluid was done using a previously described method. Of the 16 patients with a small amount of fluid, only 2 (12%) required celiotomy. Of the eight patients with a moderate amount of fluid, four (50%) required celiotomy. At celiotomy, the six patients all had small-bowel injuries. No abdominal CT scan demonstrated extravasation of oral contrast. CONCLUSION Intra-abdominal fluid as the sole finding on abdominal CT scan does not mandate immediate celiotomy in the bluntly injured pediatric patient. The patient with fluid in more than one location has a 50% chance of bowel injury. We also conclude that extravasated enteral contrast is rarely present to aid in the diagnosis of bowel injury in children.
Collapse
Affiliation(s)
- F Hulka
- Department of Surgery, Oregon Health Sciences University, Portland 97201, USA
| | | | | | | | | |
Collapse
|
21
|
Splenic nonenhancement at computed tomography: A sign of the hypoperfusion complex. Emerg Radiol 1997. [DOI: 10.1007/bf01461741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
22
|
Abstract
Traumatic duodenal perforations in children pose a diagnostic and therapeutic challenge. To identify specific diagnostic criteria and define an optimal therapeutic protocol, we reviewed all duodenal injuries treated at our institution in the past 10 years. There were 14 hematomas and 13 perforations. The diagnosis was confirmed by computed tomography (CT), ultrasound scan (US), upper gastrointestinal contrast studies (UGI), or at laparotomy. The clinical findings and CT findings of the two groups were compared. Children with suspected duodenal hematomas were treated expectantly, and children with duodenal perforations were treated surgically. Twenty-five associated injuries (10 pancreatic) occurred in 19 children. Children with perforations had higher injury severity scores (ISS) (25 v 9), but the two groups could not be differentiated based on presenting signs, symptoms, or laboratory findings. CT findings of retroperitoneal air or contrast were seen in 9 of 9 perforations and in 0 of 10 hematomas. CT findings of intraabdominal or retroperitoneal fluid, mesenteric enhancement, and thickened duodenal wall did not differentiate the two groups. Duodenojejunostomy was performed in one patient, and primary repair was performed in 11 children who had perforation. In five children, duodenostomy tube drainage with feeding jejunostomy or gastrojejunostomy were added. Complications occurred in three of four children in the first 5 years of the study and in two of nine children in the last 5 years. The decreased morbidity rate correlated with reduced time to definitive therapy (28 v 7.8 hours). Duodenal fistulae resulted in three of seven children treated without duodenostomy tube drainage and zero of five treated with drainage. Enteral feeds resumed faster (average, 12 v 27 days) if repair of perforation was combined with feeding jejunostomy or pyloric exclusion and gastrojejunostomy. Children with duodenal hematoma resumed eating an average of 16 days after injury. Only one child required surgery for persistent obstruction. The findings of retroperitoneal air and contrast extravasation on CT accurately distinguish duodenal perforation from hematoma. Conservative management of hematoma is safe and effective. Primary repair of perforation with duodenal drainage results in fewer postoperative complications, and gastrojejunostomy or feeding jejunostomy shorten the time to resumption of feeds.
Collapse
Affiliation(s)
- J Shilyansky
- Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | |
Collapse
|