Delayed Jejunal Perforation due to Taekwondo Kick: A Rare Case

Case Report

Delayed Jejunal Perforation due to Taekwondo Kick: A Rare Case

Aydin Yavuz¹, Alp Yildız¹, Hüseyin Göbüt¹, Kürşat Dikmen², Hasan Bostancı², Aybala Ağaç¹ and Hande Köksal²^*
¹Department of General Surgery, Yenimahalle Education and Research Hospital, General Surgery Clinic, Ankara, Turkey ²Department of General Surgery, Gazi University School of Medicine, Ankara, Turkey

^*Corresponding author: Hande Köksal, Department of General Surgery, Gazi University School of Medicin, Ankara, Turkey

Published: 11 Oct, 2017
Cite this article as: Yavuz A, Yildız A, Göbüt H, Dikmen K, Bostancı H, Ağaç A, Köksal H. Delayed Jejunal Perforation due to Taekwondo Kick: A Rare Case. Clin Surg. 2017; 2: 1664.

Abstract

Background: One of the most frequently injured hollow organs following blunt abdominal trauma is the jejunum; however, isolated jejunal perforation is rare.
Case Report: A 19 year-old male patient received a blow during taekwondo competition and admitted to emergency department with complaint of abdominal pain. Laboratory work-up and chest X-ray examinations did not reveal any pathology and the patient was discharged with recommendation of analgesics. Two days later, the patient presented to our emergency department with intense abdominal pain, nausea and vomiting with presence of abdominal tenderness, muscular defense, and rebound signs, whereas chest X-ray was completely normal. The patient was examined with computed abdominal tomography (CT), which revealed jejunal perforation. Following proper debridement, primary closure was performed. The patient was discharged on the postoperative 6th day.
Discussion: Although isolated intestinal injury after blunt abdominal trauma is extremely rare, it should certainly be considered particularly in cases with persistent abdominal pain. As it is particularly demonstrated in our case, failure to recognize hollow organ damage after blunt abdominal trauma by relying on the initially normal examination findings may lead to delay in the diagnosis for hours and even days as in our case. Considering that delayed diagnosis is an important cause of increased morbidity and mortality, we would like to remind that close follow-up of patients with repeated physical examinations and prolonging the hospital stay time have great benefits even if the initial examinations are normal.
Keywords: Abdominal trauma; Blunt; Jejunal perforation

Introduction

With blunt abdominal trauma, the frequency of injury to the solid organs is higher than the frequency of injury to hollow organs [1]. One of the most frequently injured hollow organs following blunt abdominal trauma is the jejunum; however, isolated jejunal perforation is rare (1%) [2]. The blunt trauma causes compression of the intestinal segment against abdominal wall and the vertebra, and sudden rise in intraluminal pressure results in a bursting type of tear in the intestinal wall [3]. In literature, there are very few reports of intestinal perforations that occurred as a result of blunt traumas due to various causes (traffic accidents, falling, being kicked, etc.) [1,4]. Since the appearance of clinical manifestations may take some time following injury to intestines after blunt trauma, the initial physical examinations may be normal. This leads to delays in diagnosis and treatment, and causes significant increases in morbidity and mortality [1,3,5].

Patients and Methods

A 19 year-old male patient received a kick during taekwondo competition, and despite wearing protective gear, he could not complete the match, and presented to emergency department of a local hospital with complaint of abdominal pain. Laboratory tests and abdominal and chest X-ray examinations did not reveal any pathology and the patient was discharged with recommendation of analgesics. Two days later, the patient presented to emergency department of university hospital with intense abdominal pain, nausea and vomiting. His vital signs were within normal limits. In physical examination, he had acute abdominal pain with presence of abdominal tenderness, muscular defense, and rebound signs. His hemoglobin (Hb) level was 12.9 g/dL and white blood cell (WBC) count was 12.300/uL, whereas chest and abdominal X-ray were completely normal (Figure 1). The patient was examined with contrast abdominal CT, which revealed pneumoperitoneum (Figure 2). The patient underwent surgery with initial diagnosis of hollow organ perforation. Diagnostic laparoscopy was performed. Since the site of perforation could not be detected, the operation was converted to open surgery, and during exploration, a jejunal perforation site was detected 60 cm away from the ligament of Treitz. The perforation site was limited with the omentum and was surrounded by fibrin clots (Figure 3). Following proper debridement, primary suturing was performed. The patient was discharged upon recovery on the postoperative 6th day.

Figure 1

Figure 1
Abdominal X-ray.

Figure 2

Figure 2
Revealed pneumoperitoneum.

Figure 3

Figure 3
The perforation site was limited with the omentum and was surrounded by fibrin clots.

Discussion

Solid organ injuries are more common in blunt abdominal trauma, with liver and spleen being the most frequently injured organs. The incidence of isolated intestinal injury following blunt trauma is about 1%, and perforation occurs only in the rate of 0.3% [1,6]. More than 75% of blunt traumas are caused by motor vehicle accidents, followed by pounding, occupational accidents, fall from height and being crushed [3]. Intestinal injury during blunt trauma is often caused by compression of the intestinal segment against anterior abdominal wall and the vertebra, which results in a sudden rise of intraluminal pressure. Sometimes the sudden forward movement of the intestines results in injury to the immobile structures such as ligament of Treitz, the ileocecal valve and mesentery root. Blunt injury to the intestines can manifest as intramural hematoma, contusion, laceration or rupture [7,8]. Hollow organ injury can present with acute abdomen during examination, although it may not manifest any signs in the early phase. Allen et al. [2] reported that diagnostic reliability of abdominal physical examination alone after blunt abdominal trauma is 30%. Following trauma, the clinical picture may be initially obscure, or perforations may occur at the late phase due to ischemia. In our case, the clinical manifestations were severe since the beginning; however, because of the normal laboratory results, and due to the fact that hollow organ injury after blunt trauma is extremely rare, the diagnosis was delayed. Therefore, in such cases, the patient should be observed closely with repeated physical examinations and imaging studies, since early diagnosis of intestinal perforation is essential to reduce morbidity and mortality. In one study by Watts et al. [9] mortality rate in case of unnoticed perforation and more than 24 hour delay in the operation was 16%, which is nearly 5 times the rate when intervention is made within the first few hours of perforation. Similarly, morbidities such as sepsis, intra-abdominal abscess and wound dehiscence are at least two times more frequent when the operation is delayed [10].
Even if the initial examination does not reveal any pathology (patient's consciousness state and administration of analgesics may be misleading), repeated examinations should be carried out. In laboratory tests, leukocytosis and elevated amylase level may be of significance. Focused abdominal sonography for trauma (FAST), abdominal CT, diagnostic peritoneal lavage (DPL), and chest-abdominal X-rays may be of guidance for detecting intestinal perforation. In our case, chest and erect plain abdominal X-rays obtained at the time of presentation and two days later were both normal, yielding false negative results which were surpassingly misleading. Our case represents a good example demonstrating the importance of appraising the clinical situation and continuing examinations with further imaging studies. On the other hand, ultrasonography does not have much of a diagnostic value particularly in the early phase of the intestinal injuries. Plain X-rays are also unreliable much of the time, as demonstrated by our case. Majority of cases do not manifest with intraperitoneal free air. CT, as the most beneficial diagnostic method in these cases has sensitivity and specificity values as 92% and 94%, respectively. CT signs that are suggestive of intestinal perforation are contrast material extravasation and presence of extraluminal free air. Other non-diagnostic but supportive signs include presence of free fluid in the absence of solid organ damage, thickening in intestinal wall and intestinal dilatation [11,12].
In treatment, explorative laparotomy and drainage of septic peritoneal fluid along with lavage are important. Additionally, prophylactic antibiotic is necessary. The type of the repair of perforation depends on the localization of the injury and the defect size. Primary repair of small defects, and resection of large defects and ischemic segments with primary anastomosis may be successfully performed even in the delayed cases [13].
Although isolated intestinal injury after blunt abdominal trauma is extremely rare, it should certainly be considered particularly in cases with persistent abdominal pain. As it is particularly demonstrated in our case, failure to recognize hollow organ damage after blunt abdominal trauma by relying on the initially normal examination findings may lead to delay in the diagnosis for hours and even days as in our case. Considering that delayed diagnosis is an important cause of increased morbidity and mortality, we would like to remind that close follow-up of patients with repeated physical examinations and prolonging the hospital stay time have great benefits even if the initial examinations are normal.

Case Report