Mechanical small bowel obstruction following a blunt abdominal trauma: A case report


Abstract

Introduction

Intestinal obstruction following abdominal trauma has previously been described. However, in most reported cases pathological finding was intestinal stenosis.

Presentation of the case

A 51-year-old male was admitted after a motor vehicle accident. Initial focused abdominal sonogram for trauma and enhanced computerized tomography were normal, however there was a fracture of the tibia. Three days later, he complained of abdominal pain, constipation, and vomiting. An exploratory laparotomy showed bleeding from the omentum and mechanical small bowel obstruction due to a fibrous band.

Discussion

The patient had prior abdominal surgery, but clinical and radiological findings indicate that the impact of the motor vehicle accident initiated his condition either by causing rotation of a bowel segment around the fibrous band, or by formation of a fibrous band secondary to minimal bleeding from the omentum.

Conclusion

High index of suspicion of intestinal obstruction is mandatory in trauma patients presenting with complaints of abdominal pain, vomiting, and constipation despite uneventful CT scan.

The most common causes of small bowel obstruction are adhesions, hernias, and malignancy. Clinical features include abdominal pain and distension, nausea, vomiting, and dehydration [1]. Intestinal obstruction following abdominal trauma has previously been described. However, in most reported cases pathological finding was intestinal stenosis 2 and 3. To our knowledge, there are no previous reports on intestinal obstruction due to a single, definite fibrous band occurring few days after blunt abdominal trauma. Prior abdominopelvic surgery is a well-known risk factor for adhesive intestinal obstruction 4 and 5. This might be especially important in patients presenting with blunt abdominal trauma, as shown in the following case.

Presentation of the Case

A 51-year-old male was admitted after a motor vehicle accident. The patient was the driver of a vehicle that had collided with another vehicle at a speed of about 80 kilometers per hour. The patient had used his seat belt at the time of accident, and the event had activated airbags with an estimated deformation of about 30-50 centimeters in the vehicle. The patient presented with an open fracture of the left tibia, but was hemodynamically stable. There were no visible deformities or abrasions of the thorax or abdomen. Focused Assessment with Sonography in Trauma (FAST) and Enhanced Computed Tomography (CT) scans were normal, apart from the tibial fracture. The patient was transferred to an orthopedic service for treatment of his tibial fracture.

His past medical history included a splenectomy 33 years ago, after a motocross accident, followed by exploratory laparotomy, through a midline incision, a month later due to mechanical intestinal obstruction. This was performed without any bowel resection, and the patient had a normal bowel function and was discharged shortly after operation. Furthermore, he had prostate cancer under active surveillance at the time of the current event. The patient was otherwise in good physical condition, and did not consume any prescription drugs.

Three days after admission, the patient complained of abdominal pain and constipation. His abdomen was distended and tender on palpation. This was initially interpreted as constipation due to use of opioid painkillers, and laxatives were prescribed. However, the condition worsened with several episodes of vomiting and increasing abdominal pain.

All vital parameters were within normal range. White blood cells count had increased from 13.1 to 19 x 109/l, and C-reactive protein from 115 to 199 mg/l over the course of 24 hours. Acute CT scan of the abdomen is the standard investigation in the authors’ department. This showed dilated small bowel with calibre change close to the ileocaecal region, and thus raising suspicion of mechanical small bowel obstruction (figure 1).

Abdominal CT scan three days after motor vehicle trauma showing intestinal ...
Figure 1.

Abdominal CT scan three days after motor vehicle trauma showing intestinal obstruction with a dilated calibre (white arrow) as well as normal small bowel segments.

The necessity of surgical intervention was evident partly because of the failing of conservative treatment and partly to exclude serious abdominal injury. A laparoscopic approach was unfavorable due to the deteriorating condition of the patient and the high risk of conversion in regards to the patient’s prior surgical procedures. An acute exploratory laparotomy was therefore performed. It showed that close to the ileocaecal valve a segment of 40 centimeters of the small bowel had rotated about 180 degrees around a fibrous band, causing necrosis of the mucosal layer. Parts of the omentum were found adherent to the abdominal wall with erosion and subsequent hemorrhage. The pelvis contained transudate with coagulated blood. There was no evidence of fecal contamination. The affected bowel segment was resected, and a primary side-to-side staple anastomosis was performed.

Histopathology of the resected segment showed necrosis of the mucosal and submucosal layers, consistent with acute inflammation with abundance of neutrophil granulocytes and fibrin coating. There were no signs of transmural perforation, polyps, or tumors.

The patient was discharged from the surgical department six days later with normal bowel function to an orthopaedic service for final treatment of his tibial fracture. The latest follow-up nine months after the operation was uneventful.

A second review of the initial trauma CT concluded that a small amount of free fluid was found adjacent to the bowels with Hounsfield units consistent with blood. There were no indications of adhesions or small bowel obstruction.

Discussion

Pathophysiological causes of small bowel obstruction include adhesions, bowel perforation, mesenteric defect, intramural hemorrhage, and localized ischemia [3]. Intestinal obstruction after trauma is rare with only few reported cases 2, 3, 6 and 7. In a majority of these cases, the pathology of obstruction was intestinal stenosis, mainly in the terminal ileum 2 and 3.

Symptoms of intestinal obstruction can occur years after a trauma event. This has been reported in patients with intestinal stenosis where localized ischaemia after blunt abdominal trauma lead to healing with fibrosis of the abdominal wall [2]. Intra-abdominal bleeding was considered the mechanism behind intestinal obstruction after blunt abdominal trauma in another case report [7]. Previous abdominopelvic surgery is a known risk factor for adhesive intestinal obstruction 4 and 5. Barmparas et al found, in a retrospective review, a significant incidence of in-hospital small bowel obstruction after exploratory laparotomy for trauma of which a fifth of the patients required surgical adhesiolysis, and in some cases resection of ischemic small bowel [8].

This patient had had previous abdominal operations, which might be the cause of formation of the fibrous band. Differential diagnoses were cancer and metastases. However, the patient did not present with any symptoms of small bowel obstruction before this event. Either the blunt abdominal trauma caused bowel rotation around a pre-existing fibrous adhesion band, especially considering that the patient developed adhesions after his splenectomy, or possibly omental bleeding with consequent formation of a fibrous adhesion band was the cause of bowel obstruction. The question remains whether a fibrous band can be formed within four days. Prominence of postoperative adhesions is usually expected after 2-3 weeks [5], but formation of adhesions after trauma cannot be excluded.

Enhanced CT is generally considered to be sensitive in terms of demonstrating hemorrhaging, perforations, and organ damage. However, missed injuries do occur, as findings can be nonspecific and subtle [3], as demonstrated in this case.

To our knowledge, this is the first report on adhesive obstruction following trauma where a definite fibrous band was found. Hefny et al described adhesive intestinal obstruction in a patient with no former abdominal surgery seven weeks after blunt abdominal trauma, without any single, definite fibrous band [6].

In our department, trauma guidelines dictate admission for at least 12 hours for patients with no apparent injuries. This period cannot exclude intestinal obstruction such as in this case. Had the patient not presented with his tibial fracture, he would have most likely been discharged after 12 hours. The question remains how to prevent a similar incident, and whether this can be achieved by altering our guidelines or simply increasing awareness of mechanical instruction as a complication to abdominal trauma. Although this case report is limited by its nature, it has the potential of raising awareness and triggering future studies with the purpose of developing adequate guidelines for trauma patients.

Conclusion

High index of suspicion of intestinal obstruction is needed in trauma patients presenting with complaints of abdominal pain, vomiting and constipation despite uneventful trauma CT scan.

Awareness of a patient’s surgical history and appropriate monitoring for early and late complications is important. Moreover, patient-tailored approach is highly recommended for trauma patients. Patients presenting with risk factors for complications after trauma should not be discharged early.

Cecal Volvulus Presenting as Epigastric Swelling and Mimicking Gastric Volvulus.


Caecal volvulus is the second most common volvulus involving the large bowel, following sigmoid volvulus. It usually manifests as closed-loop obstruction and patient usually presents with early gangrene and perforation. It is unusual for caecal volvulus to present as an epigastric swelling. We report a case of caecal volvulus in a 90-year-old patient who presented with an epigastric swelling.Case ReportA 90-year-old man presented to surgical emergency with complaints of progressive abdominal distension, obstipation and pain for 3 days; he had no associated comorbid conditions. On examination, the patient was dehydrated and had tachycardia. The supra-umbilical half of the abdomen was distended and associated with tenderness and guarding. X-rays findings were of multiple air fluid levels with a large air filled viscus occupying the upper abdomen (Figure 1).Computer tomography (CT) at the level of L2 also showed a large air filled viscus. On exploration, large bowel popped into the operative field as soon as the peritoneal cavity was opened (Figure 2).It included the cecum and ascending colon which were grossly distended, reaching upto 14 cm in diameter, rotated on the longitudinal axis clockwise and lying in the upper abdomen. There were signs of rupture of the tenia coli and impending perforation. The patient underwent derotation of the gut with right hemicolectomy and ileo-transverse anastomosis. Postoperative period was uneventful and patient was discharged in a stable condition and is healthy on follow up.

Discussion

The term volvulus is derived from the Latin word volvere (“to twist”.) Cecal volvulus is the second most common site of colonic volvulus after the sigmoid colon. It is regarded as a misnomer because, in most patients, the torsion is located in the ascending colon. Cecal volvulus is essentially a closed-loop obstruction that may lead to vascular compromise with consequent gangrene and perforation. It is a disease of the elderly, predominately affecting women.[1]

Cecal volvulus is responsible for 10%-15% of all cases of large-bowel obstruction; the most common site of large-bowel torsion being the sigmoid colon (80%), followed by the cecum (15%), the transverse colon (3%), and the splenic flexure (2%).[2] People with incomplete intestinal rotation generally have inadequate right colon fixation which is associated with clockwise torsion of the cecum, terminal ileum, and ascending colon. Based on autopsy reports, sufficient cecal mobility for volvulus and bascule formation is found in 11% and 25% of adults, respectively.[3] Prior abdominal surgery with colonic mobilization, recent surgical manipulation, adhesion formation, congenital bands, distal colonic obstruction, pregnancy, pelvic masses, extreme exertion, and hyperperistalsis have all been implicated as causative.[4]

The usual presentation is acute obstruction with progression to cecal gangrene and perforation. There is an associated distension of the abdomen, usually in the lower part. In contrast gastric volvulus presents as epigastric pain, upper abdominal distension and enderness. The diagnosis is based on the combination of clinical presentation, plain abdominal x-ray and barium enema. In gastric volvulus the Borchardt’s triad of pain, retching, and the inability to pass a nasogastric tube is diagnostic and reportedly occurs in 70% of cases.[6] This triad was absent in the present case. X-ray findings of cecal volvulus differ from gastric volvulus in its location being in the right lower abdomen rather than the epigastrium or the thorax.[7] CT is widely replacing barium contrast imaging as the preferred imaging modality for the diagnosis of volvulus. However in this case it was unable to identify the segment of bowel involved in the volvulus.

Early diagnosis is essential to reduce the substantial morbidity and mortality. The treatment is essentially surgical. Five surgical procedures have been used in the treatment of cecal volvulus: detorsion alone, cecopexy, cecostomy, both cecopexy and cecostomy, and resection. There are reports of decompression of cecal volvulus using a colonoscope or decompression tube and this modality of treatment can be given a chance.[8] The recurrence rate for detorsion alone was 13%, which is the same recurrence rate as for cecopexy.[9] Cecostomy had a recurrence rate of 1%, but there is a high incidence of wound infection, limiting the use of this procedure mainly in moribund patients. Resection eliminates the risk of recurrence entirely and is the procedure of choice in stable patients.

Key Points

  • Caecal volvulus is an uncommon cause of largebowel obstruction, which is commonly associated with gangrene and perforation.
  • A high degree to suspicion is required to diagnose this condition early.
  • Surgical management remains the treatment of choice in this condition.

References

  1. Rabinovici R, Simansky DA, Kaplan O, Kaplan O, Mavor E. Cecal volvulus. Dis Colon Rectum. 1990;33:765–69.
  2. Rogers RL, Harford FJ: Mobile cecum syndrome. Dis Colon Rect. 1984;27:399-402.
  3. Wolfer JA, Beaton LE, Anson BJ. Volvulus of the cecum. Anatomical factors in its etiology: report of case. Surg Gynecol Obstet. 1942;74:882-94.
  4. Margolin DA, Whitlow CB. The pathogenesis and etiology of colonic volvulus. Semin Colon Rectal Surg. 1999;10:129-138.
  5. Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum. 2002;45:264-67.
  6. Dibra A, Rulli F, Kaçi M, Çeliku E, Draçini X. Acute right intrathoracic gastric volvulus. A rare surgical emergency. Ann Ital Chir. 2013;84:205-07.
  7. Carter R, Brewer LA 3rd, Hinshaw DB. Acute gastric volvulus. A study of 25 cases. Am J Surg. Jul 1980;140(1):99-106.
  8. Janardhanan R, Bowman D, Brodmerkel GJ Jr, Agrawal RM, Gregory DH, Ashok PS. Cecal volvulus: decompression and detorsion with a colonoscopically placed drainage tube. Am J Gastroenterol. September 1987;82(9):912-14.
  9. Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the literature. Dis Colon Rect. 1988;31:445-49.

The calcified abdominal cocoon.


A 45-year-old man with end-stage renal failure secondary to Alport syndrome, who had received maintenance peritoneal dialysis for 19 years, presented with abdominal pain and haemodynamic instability.

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His abdomen was tender and 500 mL of fresh blood was drained from the peritoneal dialysis catheter. Following resuscitation, an abdominal CT scan showed thickened bowel wall and extraordinary calcification of abdominal viscera .At laparotomy, exploration of the abdomen was precluded by severe calcification of the abdominal wall and bowel loops . Blood was arising from the pelvis, which was subsequently packed with gauze, arresting the haemorrhage. The packs were removed after 72 h and the patient was transferred to haemodialysis. He was discharged home on day 36. The radiographic and intraoperative appearances were typical of advanced, sclerosing, encapsulating peritonitis,1 or so-called abdominal cocoon, a well recognised complication of long-term peritoneal dialysis, with ectopic calcification secondary to tertiary hyperparathyroidism. Sclerosing encapsulating peritonitis is one of the most serious complications of peritoneal dialysis and is associated with a high mortality rate, even if peritoneal dialysis is discontinued. Patients usually present with symptoms of bowel obstruction. Unfortunately, there is no reliable therapy, although tamoxifen and surgery are used.

Source: Lancet