Isolated Jejunal Rupture After Blunt Trauma
Andrew Hunt, MD; Gary Dorshimer, MD; James Kissick, MD; Sean Ryan, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO.11 - NOVEMBER 2021
In Brief: Jejunal ruptures and other hollow viscus injuries are relatively uncommon manifestations of blunt abdominal injury that can often be masked by more serious injuries, such as solid-organ ruptures. Also, symptoms can be quite subtle and slow to appear. When the injury is suspected, the results of serial exams can be used to determine the need for laparotomy to establish the diagnosis. This report of an isolated jejunal rupture in a professional hockey player, in which the initial work-up was negative for any serious pathology, illustrates the need for continued vigilance in cases of blunt abdominal trauma.
Although much less common than injuries to the extremities, blunt injuries to the thorax and abdomen can occur in many activities, especially in motor vehicle accidents and in sports involving sudden deceleration and impact such as football, ice hockey, and downhill skiing. The abdomen is largely unprotected in most contact sports, and significant injury can occur when the lower ribs and contracted back or abdominal muscles are unable to prevent the transmission of blunt force to the visceral organs. In addition to solid-organ or diaphragm rupture, rectus sheath hematomas, and traumatic hernias, the possibility of hollow viscus injury (HVI) must also be considered following blunt abdominal trauma.
A 28-year-old professional ice hockey player sustained blunt lower abdominal trauma during an evening game after being checked into an open door to the bench. He immediately fell to the ice and had difficulty rising because of lower abdominal pain. Physical exams in the locker room revealed abdominal pain and tenderness. Although he was able to walk, he had great difficulty standing upright due to recurrent lower abdominal pain spasms. He was taken to the hospital where an abdominal-pelvic helical computed tomography (CT) scan, with and without intravenous (IV) contrast, failed to detect signs of intra-abdominal or pelvic trauma. Blood tests and urinalysis were unremarkable. Because he was feeling better and because no problems were detected on radiographic imaging or lab testing, he was discharged from the emergency department and went back to the team's hotel.
Overnight, he continued to have lower abdominal pain with movement and, by the next morning, found it difficult to arise and walk. He ate and drank without nausea or vomiting but developed an increasing lack of appetite. He was brought back to the hospital where exams revealed new tenderness and guarding in the lower anterior abdomen. The pain was near the rectus muscles and was exacerbated by the patient's attempts to rise from the supine position. Although he was afebrile, had stable vital signs, and had normal laboratory results on repeat testing, he was admitted for pain control and observation.
The next day his pain was unchanged, but he had some abdominal distension and he noted pain in his left shoulder. A repeat CT scan was performed, revealing the development of a large left-sided pneumoperitoneum (figure 1) as well as a small new left pleural effusion without any obvious intestinal perforation.
Diagnosis and Treatment
Approximately 36 hours postinjury, a midline laparotomy was performed. Full abdominal exploration revealed a 0.5-cm jejunal rupture approximately 15 cm from the ligament of Treitz. Interestingly, there was no evidence of other abdominal injuries. A partial small bowel resection with a side-to-side anastamosis was performed without any operative complications.
Although the patient developed transient pulmonary infiltrate and persistent small pericolic fluid collections postoperatively, he had a full recovery with normal bowel movements and normal lab indices and was discharged 9 days after admission.
While more commonly a result of penetrating trauma, the incidence of HVI (eg, ruptures of the stomach, duodenum, jejunum, ileum, or colon) following blunt trauma has been reported as less than 1% to 18% of all blunt trauma for both children and adults (1-3). Athletic injuries leading to blunt abdominal trauma with HVI are rare. Rarer still are isolated cases of jejunal rupture in athletes. There have been at least three reported cases in football and soccer players due to kicks or blows to the abdomen (4,5), but the number caused by sports injuries is most likely higher because many cases have been broadly classified in other studies as "discrete blows to the abdomen." We are not aware of any previously reported cases in hockey players.
The most commonly reported mechanism of jejunal rupture and of blunt abdominal trauma in most adult cases is motor vehicle accidents with associated seat-belt injuries (especially lap belts). Various nonathletic mechanisms of rupture have been reported in adults and children, including trauma from child abuse, use of the Heimlich maneuver, spontaneous rupture, bezoar impaction, use of Sengstaken-Blakemore tubes, and massive gastrointestinal bleeding. Possible sports-related mechanisms include falls off equipment or horses, pile-ons and spearing in football, and accidents involving handlebars in bicycling.
The rupture is presumed to occur when abdominal compression creates closed loops of bowel that rupture from increased intraluminal pressure (1). Neugebauer et al (6) have speculated that direct compression of fluid and gas-filled bowel against the spinal column is the main cause of rupture.
The location of HVI also appears to depend on the age of the patient. Injuries to the jejunum or ileum and duodenum appear to predominate in children, and injuries to the jejunum or colon predominate in adults. Other injuries to the small bowel include serosal contusions, hematomas, and mesenteric tears (presumably from shearing forces on the mesentery). In addition, the likelihood of HVI increases as the number of solid viscus injuries increases (7). Acute abdominal symptoms and signs of shock or gross hematuria suggest significant intra-abdominal injury and warrant urgent transport to the hospital.
The initial clinical exam can be unremarkable because signs of HVI may take time to develop. Patients who have a mechanism of injury that suggests serious injury yet have mild initial pain may require hospital observation to monitor symptoms. Serial exams may reveal persistent abdominal pain with signs of an intestinal rupture such as chemical or bacterial peritonitis, referred shoulder pain from irritation of the diaphragm, loss of normal respiratory motion of the abdomen, or blood in the stool from intermucosal hemorrhage. Because delayed rupture is also possible, clinicians should counsel patients to return immediately for treatment if pain becomes worse.
The diagnosis of jejunal rupture and other HVI following blunt abdominal trauma can be difficult. Controversy exists as to whether abdominal CT, diagnostic peritoneal lavage (DPL, table 1), or physical exam alone is the best way to diagnose HVI in patients with blunt trauma. DPL is not initially sensitive for HVI because there is little immediate spillage of enteric contents, but this changes as time from injury increases. DPL is initially sensitive for solid-organ injuries. Some combination of plain x-rays, abdominal CT, DPL, and abdominal ultrasound is used to determine whether patients need exploratory laparotomy or can be observed using serial exams and studies.
Diagnostic radiographic findings seen on plain film include free air under the diaphragm or along the abdominal wall. Positive CT findings include extravasation of IV or oral contrast medium (such as meglumine diatrizoate), unexplained pneumoperitoneum, a localized distended bowel loop, or streaking of the mesentary. These findings, however, are rarely seen. A skilled clinician may also find that other imaging modalities, such as ultrasound, are highly specific with moderate sensitivity in detecting intra-abdominal fluid. Negative CT scans and/or DPLs do not rule out bowel injury. Intra-abdominal injury is excluded by documenting the return of normal bowel function. This usually occurs within 24 hours in children who do not have intra-abdominal injuries (8). In adults, bowel function may return in 24 hours, but it can take longer.
Patients who have trace amounts of fluid in the pelvis with no other signs of injury can be safely managed nonoperatively; however, moderate-to-large amounts of free fluid seen on CT are a strong indication for exploratory laparotomy. The goal is to avoid the development of peritonitis, intra-abdominal abscesses, necrotizing abdominal wall abscesses, and sepsis that may arise from delays in diagnosis, yet avoid needlessly exposing patients to potential complications of abdominal surgery. Despite these risks, Frick et al (1) have stated that delays up to 36 hours don't increase morbidity and mortality. Allen et al (2) and Robbs et al (3) disagree and stress that therapeutic delays of more than 24 hours are associated with increased mortality. Canty et al (8) recommend extended observation and nonoperative management for children.
Weighing the Evidence
HVI and jejunal rupture are extremely rare in sports settings, but any blunt abdominal trauma should raise suspicion and increase surveillance for delayed symptoms. Test results are usually negative soon after the injury, and the diagnosis can easily be overlooked in patients who have solid-organ ruptures, multiple injuries, or head injuries that impair consciousness. The risks of delayed treatment must be weighed against the possible complications of abdominal surgery to achieve the best possible outcome.
Dr Hunt is director of the Excel Primary Care and Sports Medicine Department at Condell Medical Center in Libertyville, Illinois. Dr Dorshimer is program director of the Primary Care Sports Medicine Fellowship, and Dr Ryan is a resident in general surgery at Pennsylvania Hospital at the University of Pennsylvania in Philadelphia. Dr Kissick is a staff physician at the Palladium Sports Medicine Center in Kanata, Ontario, Canada. Address correspondence to Andrew Hunt, MD, 444 W Hawthorne Ct, Lake Bluff, IL 60044; e-mail to [email protected].