hjury Vol. 28, No. 5-6, pp. 421-423, 1997 0 1997 Elsevier Science Ltd. All rights reserved

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Perforation of the transverse colon as a result of minor blunt abdominal trauma

D. Johnson and D. B. Hamer Department of General Surgery, Northampton General Hospital, Cliftonville, Northampton, UK

Injury, Vol. 28, No. 5-6,421-423, 1997

Introduction Blunt injuries to the colon are uncommon, and repre- sent only 3-7 per cent of all injuries to the co10n14. There are frequently associated serious injuries with high morbidity and mortality2,3,5.

We report here a unique case of a patient who sustained minor blunt trauma to the abdomen and then presented with a delayed colonic perforation as the only injury.

Case report A previously fit 20-year-old man fell on to the kerb at the roadside, landing on the left side of his abdomen. He was taken to the local casualty department. No serious intra- abdominal injury was suspected and the patient was discharged home with oral analgesia. After his discharge from the casualty department, he became constipated and suffered from occasional vomiting, was anorexic and continued to have left upper abdominal pain. One week after the accident, he opened his bowels for the first time and passed 500 ml of dark red blood PR, he was then admitted to hospital.

On admission, he looked unwell, was pyrexial and demonstrated signs of dehydration. His cardiovascular system was stable with a pulse of 90 and a blood pressure of 110/60. On inspection of his abdomen there was no evidence of any external injuries. Palpation revealed a soft abdomen with some mild tenderness in the left upper quadrant but no evidence of peritonitis. Bowel sounds were normal. Rectal examination and rigid sigxnoidoscopy confirmed the presence of dark red blood mixed in with loose motions.

Blood investigations revealed a haemoglobin of 10.2 fl, suggesting moderate blood loss, and a white cell count of 26 x 10’. All other blood tests were normal.

An erect chest X-ray showed no thoracic abnormality and no air under the diaphragm. A plain supine abdominal film revealed a large air-filled shadow separate from the stomach in the left upper abdominal quadrant (Figure 1). A CT scan of the abdomen was obtained, which confirmed

this to be free air in the lesser sac (Figure2). No other abnormalities were noted.

Laparotomy revealed a retroperitoneal haematoma and an extensive inflammatory mass involving the transverse colon which had perforated into the lesser sac. There was no evidence of ischaemia of the bowel.

The involved area of colon was resected and a primary anastomosis performed. The patient was discharged on day 9 having suffered no post operative complications.

Discussion Blunt trauma to the abdomen is more likely to damage solid organs such as the liver, the spleen, the pancreas and the kidneys. Indeed, the colon is involved in blunt trauma in only 3-7 per cent of all cases, and when it is involved, over 90 per cent of incidents are associated with multiple injuries2,7.5. When the colon is perforated as a result of blunt trauma, it is the sigmoid colon which is most often affected5s6.

Colonic injuries are notoriously difficult to diagnose6 and the phenomenon of delayed colonic perforation as a consequence of blunt abdominal trauma is rare and sparsely mentioned in the surgical literature’*5,7. Possible mechanisms for the delay in the appearance of colonic injury include:

(1) intramural haematoma, which subsequently liquefies and leads to perforation’,‘.

(2) delayed perforation secondary to abscess forma- tion from an infected intramural haematoma’J,4.

(3) vascular compression by a mesenteric haema- toma, leading to bowel wall infarction’,7.

(4) the injury being initially walled-off by omentum4.

There are no reliable symptoms or signs to lead to a definitive diagnosis of hollow organ injury, and abdominal guarding, rebound tenderness and auscul- tation of bowel sounds are notoriously unreliablex. Radiological evidence of free intra peritoneal air is also unreliable and is seen in less than 50 per cent of patients with intestinal perforation’. Peritoneal lavage may be normal at the time of admission unless there is associated haemoperitoneum. Some claim that CT

422 Injury: International Journal of the Care of the Injured Vol. 28, No. 5-6,1997

Figure 1. Plain supine abdominal radiograph. The black arrow points to air in the stomach. The white arrow points to separate air-filled shadow.

the

Figure 2. Axial CT image demonstrating air in the stomach (S) and in the lesser sac (LS).

Case reports 423

scanning is the investigation of choice in suspected colonic injuries” while others have found this investi- gation to be unhelpful”.

To our knowledge this is the first case of minor blunt trauma to the abdomen leading to colonic perforation. Because the perforation was positioned posteriorly into the lesser sac, the faecal contamina- tion was contained and the patient did not develop signs of peritonitis.

References 1 Bubenik O., Meakins J. L. and McLean A. I’. H. Delayed

perforation of the colon in blunt abdominal trauma. Catr ] Surg 1980; 23(5): 473.

2 McKenzie A. D. and Bell G. A. Non-penetrating injuries of the colon and rectum. Surg Clin North Am 1972; 52: 735.

3 Hunt K., Garrison R. and Fry D. Perforation injuries of the gastrointestinal tract following blunt abdominal trauma. Am Surg 1980; 46: 100.

4 Rowlands B. Intestinal injury due to non-penetrating abdominal trauma. injury 1977; 8: 284.

5 Stahl K. D., Geiss A. C. and Bordan D. L. et al. Blunt trauma and delayed colon injury. Current Surgery 1985; 42(l): 4.

9 Federle M. I’., Goldberg H. I. and Kazer J. A. et al. Evalu- ation of abdominal trauma by computed tomography.

6 Wisner D. H., Chun Y. and Blaisdell F. W. Blunt intest-

Radiology 1981; 138: 637.

inal injury. Arch Surg 1990; 125(10): 1319. 7 Wightman J. Delayed traumatic rupture of the colon

with colocutaneous fistula. Br Med J 1967; 2: 93. 8 Sinclair, M. C., Moore, T. C. and Asch M. J. et al. Injury

to hollow abdominal viscera from blunt abdominal trauma in children and adolescents. Am ] Surg, 1974, 128, 693.

Paper accepted 29 March 1997.

Requests for repritzts should be addressed to: Mr. D. B. Hamer, Consultant Surgeon, Northampton General Hospital NHS Trust, Cliftonville, Northampton, NNl 5BD, UK.