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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 65-67

Double ileal stenosis following the blunt trauma abdomen in a child


Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication23-Feb-2018

Correspondence Address:
Dr. Aditya Pratap Singh
Near The Mali Hostel, Main Bali Road, Falna, Pali, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_65_17

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  Abstract 


The incidence of blunt abdominal trauma has increased in recent years; however, relatively little attention has been paid to instances of its sequelae, especially in childhood. Small bowel stricture following a history of abdominal trauma is a rare cause of small bowel obstruction and there have been few reports examining its occurrence. We are presenting here a case of posttraumatic double ileal stenosis in a 4-year female child.

Keywords: Blunt abdominal trauma, children, intestinal stenosis, mesenteric injury


How to cite this article:
Singh AP, Gupta AK, Mathur V, Barolia DK. Double ileal stenosis following the blunt trauma abdomen in a child. J Clin Sci 2018;15:65-7

How to cite this URL:
Singh AP, Gupta AK, Mathur V, Barolia DK. Double ileal stenosis following the blunt trauma abdomen in a child. J Clin Sci [serial online] 2018 [cited 2019 Oct 14];15:65-7. Available from: http://www.jcsjournal.org/text.asp?2018/15/1/65/226039




  Introduction Top


One reported late sequela following blunt abdominal trauma (BAT) is posttraumatic intestinal stenosis (PIS). When seatbelt injuries are excluded, only a few pediatric PIS cases have been reported in the literature.[1] Patients with BAT are often managed without surgical intervention if there are no signs of bowel perforation or hypovolemic shock due to blood loss. In blunt abdominal injury, mesenteric injuries and small bowel hematoma may go undiagnosed.[2]


  Case Report Top


A 4-year-old female child presented to us with complaints of the bilious vomiting, abdominal distension, and not passing motion for the past 5 days. The patient had intermittent episodes of bilious vomiting and gradual abdominal distension. She fell down from a vehicle 6 weeks before and erect abdominal radiograph at the time of injury was normal [Figure 1]a. For 3 days after trauma, she had a mild abdominal pain with vomiting, but then felt well and discharged. She came for follow-up after 4 weeks with no complaints. At the readmission, abdominal examination revealed abdominal distension with visible bowel loops. Routine blood investigations were within normal limits except hemoglobin which was 8.0% g. X-ray abdomen erect showed multiple air-fluid levels [Figure 1]b. Ultrasonography abdomen suggested moderate ascites with normal organ systems. Contrast-enhanced computed tomography (CECT) abdomen was normal [Figure 2]a. We made preoperative diagnosis of intestinal obstruction. An emergency laparotomy was performed, there was two stenosis 2 cm apart in the distal ileum and moderate reactionary fluid [Figure 2]b. There was no mesentery hematoma or adhesion and resection of the ileum containing stenosis with ileoileal anastomosis done in two layers. We were not expecting the intraoperative finding. Pathological findings showed large area of the mucosal ulceration covered by acute inflammatory exudates and inflammatory granulation tissue. The submucosa shows patchy fibrosis. The inflammatory cells were extending up to muscle layer and serosa showed congested vessels. The patient was discharged uneventfully after 7 days.
Figure 1: (a) X-ray abdomen erect after trauma (b) at the time of readmission

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Figure 2: (a) Contrast-enhanced computed tomography abdomen image (b) Resected specimen of the double stenotic segment of the ileum

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  Discussion Top


Delayed presentations of mesenteric injuries following traffic accidents and attributed to seatbelt use have been documented in children. However, other causes of BAT may also lead to PIS through other mechanisms as in our case. A specific history of bicycle handlebar injury, child abuse, or a direct blow to the abdomen should heighten suspicion of mesentery injury.[3] In these cases, visible signs of injury may not be always present.[4] A history of BAT was elicited in our case due to fall down from height before 6 weeks.

Delayed small bowel obstruction after BAT is a rare clinical entity, with only a few anecdotal case reports described in the world literature. Some controversy exists about the exact cause of the intestinal stenosis. The pathological mechanism causing small bowel obstruction is local ischemia. This heals with fibrosis and stricture which causes the delayed onset of symptoms. Two separate mechanisms for local ischemia are known. In the first, injury to the mesentery impairs the blood supply to the bowel, resulting in a stenotic segment, and often adjacent to a mesenteric tear. This method of injury is more common in the proximal jejunum and distal ileum. The mesentery is fixed at these points and may be more likely to tear in response to a shearing force.[4] In the second, the mesentery is not torn, but direct trauma causes sufficient damage to the small bowel to result in hemorrhagic mucosal infarction as in our case. Subsequent healing by fibrosis gives cicatricial stenosis and secondary small bowel obstruction.[5] Pathological examinations of resected specimens from our subject confirmed mucosal and mural fibrosis with inflammation and granulation tissue. Although both small and large intestinal stenoses have been reported, stenosis developed in the small intestine in our case.[6] Posttraumatic bowel lesions may also be found in the colon, mainly on the left side, specifically the sigmoid colon.[7] In addition, our patients had a double stenotic segment, although multiple stenotic segments have also been reported.[3]

In our case, there was no mesentery hematoma, adjacent bowel wall injury, but localized ischemic changes were present.

In most cases, the patient is managed conservatively till resolution of the initial symptoms of trauma. However, symptoms of small-bowel obstruction appear four to 8 weeks after the initial trauma; though in some cases it has been reported to occur as early as 1 week to as long as 26 years after the injury.[8] While in our case, it was appeared after 6 weeks.

Because of the tendency for late presentations, preoperative diagnosis of PIS is frequently difficult.[3] Furthermore, the clinical manifestations and radiographic features of PIS are mimicked by various intestinal diseases and are characterized by obstructive symptoms. Few adult cases have been reported in the literature, these were diagnosed preoperatively with small or large bowel barium investigation.[9]

In children, however, contrast studies are of limited value since the lesion is usually limited to the small bowel. Therefore, investigation of the type of injury is the first step in the preoperative diagnosis of PIS. Any child who suffers a possible BAT, including bicycle handlebar injury, child abuse, or a direct blow to the anterior abdomen, and in whom abdominal pain, bilious vomiting, and/or peritoneal signs develop even months or years later, may be suspected of having PIS. In appropriate cases, preoperative diagnosis may be performed using contrast intestinal passage CT. Under this particular circumstance, enteroclysis may demonstrate the localization of the stricture, showing a narrowed, rigid loop.[4],[10] Although angiography may further demonstrate mesenteric vessel occlusion and provide additional information concerning mesenteric injury.[10] Regardless of the pathophysiology of this complication of BAT, the diagnosis of posttraumatic small bowel stricture should be suspected when a patient presents with features of bowel obstruction weeks, or even years, after sustaining abdominal injury. Plain abdominal films may confirm the diagnosis particularly during a bout of colicky pain.

Our case diagnosed with only X-ray abdomen erect which showed multiple air-fluid level and clinical findings, while CECT abdomen was normal.

Because of the high frequency of BAT in childhood, a history of unrecognized, typical BAT should be carefully investigated in cases presenting with intermittent colic abdominal pain and/or partial intestinal obstruction findings. If present, PIS should be considered and investigated. Primary treatment is partial resection of the stenotic segment and then anastomosis, as performed in our cases.[11]


  Conclusion Top


This report highlights some well-recognized features of posttraumatic stenosis of the small bowel. Trauma may be trivial. This is a rare case of intestinal occlusion secondary to double small bowel stenosis due to abdominal blunt trauma. This diagnosis should be considered in all patients presenting with abdominal pain and intestinal obstruction some weeks after BAT.

Acknowledgment

The authors would like to thank Dr. Maryem Ansari, pathologist, Assistant professor, SMS Medical College, Jaipur, Rajasthan, India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jones VS, Soundappan SV, Cohen RC, Pitkin J, La Hei ER, Martin HC, et al. Posttraumatic small bowel obstruction in children. J Pediatr Surg 2007;42:1386-8.  Back to cited text no. 1
[PUBMED]    
2.
Bougard V, Avisse C, Patey M, Germain D, Levy-Chazal N, Delattre JF, et al. Double ischemic ileal stenosis secondary to mesenteric injury after blunt abdominal trauma. World J Gastroenterol 2008;14:143-5.  Back to cited text no. 2
    
3.
Lynch JM, Albanese CT, Meza MP, Wiener ES. Intestinal stricture following seat belt injury in children. J Pediatr Surg 1996;31:1354-7.  Back to cited text no. 3
[PUBMED]    
4.
Lane TM, Williams TG. Small bowel obstruction following blunt abdominal trauma. Injury 1998;29:484-5.  Back to cited text no. 4
[PUBMED]    
5.
Lane TM. Small-bowel obstruction after blunt trauma. J R Soc Med 2000;93:498.  Back to cited text no. 5
    
6.
Balupuri S, Stock SE. Post traumatic large bowel stricture. Injury 1999;30:68-9.  Back to cited text no. 6
[PUBMED]    
7.
Lublin M, Chauvin S, Kashani M, Ibrahim I, Kahn M. Delayed colonic stricture and obstruction after blunt abdominal trauma: A case report and review of the literature. J Trauma 2004;57:193-5.  Back to cited text no. 7
    
8.
Hirota C, Iida M, Aoyagi K, Matsumoto T, Yao T, Fujishima M, et al. Posttraumatic intestinal stenosis: Clinical and radiographic features in four patients. Radiology 1995;194:813-5.  Back to cited text no. 8
    
9.
Lee-Elliott C, Landells W, Keane A. Using CT to reveal traumatic ischemic stricture of the terminal ileum. AJR Am J Roentgenol 2002;178:403-4.  Back to cited text no. 9
    
10.
Tsushima Y, Yamada S, Aoki J, Endo K. Ischaemic ileal stenosis following blunt abdominal trauma and demonstrated by CT. Br J Radiol 2001;74:277-9.  Back to cited text no. 10
    
11.
Imamoǧlu M, Sarıhan H. Intestinal stenosis from mesenteric injury after blunt abdominal trauma in children: Case reports. Ulus Travma Acil Cerrahi Derg 2013;19:183-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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