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CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 4  |  Page : 371-373  

Blunt trauma abdomen-induced jejunal perforation with appendicitis


1 Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Obstetrics and Gynaecology, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication2-Aug-2018

Correspondence Address:
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/MJDRDYPU.MJDRDYPU_136_17

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  Abstract 


Keywords: Appendicitis, blunt trauma abdomen, jejunal perforation


How to cite this article:
Singh AP, Gupta AK, Pardeshi R, Barolia DK. Blunt trauma abdomen-induced jejunal perforation with appendicitis. Med J DY Patil Vidyapeeth 2018;11:371-3

How to cite this URL:
Singh AP, Gupta AK, Pardeshi R, Barolia DK. Blunt trauma abdomen-induced jejunal perforation with appendicitis. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Oct 22];11:371-3. Available from: http://www.mjdrdypv.org/text.asp?2018/11/4/371/238156




  Introduction Top


Trauma and appendicitis are the most common conditions of childhood for which surgical consultation is sought in emergency departments. Occasionally, appendicitis and trauma exist together, which causes an interesting debate whether trauma has led to appendicitis. Trauma has also been reported very rarely in the literature as a cause of appendicitis.[1],[2] In the setting of trauma, traumatic appendicitis is a rare cause of operative intervention. We present a very rare case of appendicitis after a bicycle handlebar injury with jejunal perforation.


  Case Report Top


A 10-year-old boy was presented to us with the complaint of the pain abdomen after sustaining blunt abdominal trauma (BAT) to his central abdomen secondary to bicycle handlebar injury. He got injury 2 days back. There was no history of the pain abdomen before trauma. On physical examination, blood pressure was 110/60 mmHg and pulse rate was 130 beats/min. There was a visible sign of the trauma around the umbilicus [Figure 1]a. Local examination of the abdomen revealed tenderness and rigidity. Routine blood investigations showed total leukocyte count-9000/cm and deleted in liver cancer P-60% and L-30% and others were within normal limits including renal function test and serum electrolytes. X-ray abdomen erect showed gas under both domes of the diaphragm [Figure 1]b. Ultrasonography abdomen showed normal organ systems with minimal to mild ascites and low-level echoes. We explored the patient with right supraumbilical incision; on exploration, there was a 1 cm × 1 cm size perforation 12 cm from the DJ junction without gross contamination. We repaired the perforation in single layer. There was no evidence of a fecalith, solid organ injury, bruising, or mesenteric hematoma. Meckel's diverticulum was absent, but appendix was inflammed and edematous; so, appendicectomy was performed [Figure 2]. The postoperative course was uneventful. The patient was discharged on the 7th postoperative day. Histopathological report showed acute appendicitis.
Figure 1: (a) Photo showing trauma marks over abdomen, (b) X-ray abdomen showed gas under both of diaphragm

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Figure 2: Inflamed and edematous appendix

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  Discussion Top


Traumatic appendicitis has been sporadically reported in the literature over the last 100 years. It has been found to be a very rare cause of appendicitis. The most commonly encountered pathophysiological mechanism of appendicitis is obstruction of its lumen by miscellaneous factors such as inspissated stool, foreign bodies, and intestinal parasites. BAT has been suggested to be another etiological factor causing appendicitis.

Diagnosis of TA is not easy in a child as the trauma or its complications are themselves able to elicit pain. This may cause delays in both diagnosis and treatment.[3] Clinical suspicion is of utmost importance in such patients.

The relationship between appendicitis and trauma is not yet clearly identified. There are reports that discuss the effect of direct trauma as an etiology. The pathological process of the development of acute appendicitis has been attributed to different mechanisms. The first proposed mechanism is increased intra-abdominal pressure (IAP) in direct injury.[2] Pressure within the appendix may be increased by any force which decreases intra-abdominal space.[2] This force must be suddenly exerted. The second explanation is that blunt trauma might have a direct effect on the appendix with subsequent appendiceal edema, inflammation, and/or hyperplasia of intrinsic lymphoid tissues, all of which could result in obstruction of the appendiceal lumen. The third mechanism is explained by a combination of appendiceal fecalith and cecal trauma. In the presence of fecalith, a direct blow or crushing injury delivered over the cecum may cause a true traumatic lesion or forcible expulsion of gas and fecal contents into the organ that increases luminal pressure. Minute fissures in the mucosa or lacerations may occur permitting invasion of bacteria into the submucous coat. This leads to complete obstruction, inadequate drainage, defective circulation, and subsequently gangrene (as in our case) and spontaneous perforation.[2] The fourth explanation states that stretching of the appendiceal orifice is the cause of appendicitis. The cecum, as the widest part of the colon, is most susceptible to distension with increases in intracolonic pressure. This leads to stretching of the appendiceal orifice. Subsequent acute inflammation in response to this stretching trauma may have led to the development of an obstructive appendicitis.[4] Indirect trauma might also cause appendicitis. This is either caused by increased IAP or irritation caused by muscle contractions. Power contractions of the iliopsoas might irritate the appendix causing adhesions, bands, angulations, kinks, or obstructions.[2] Some authors attribute appendicitis secondary to direct and indirect trauma to hypoperfusion with subsequent mucosal edema and appendicitis.

The indirect role of BAT in the formation of appendicitis is much more obscure. It is well known that IAP increases in varying degrees in every BAT case.[5],[6] The mechanism of this increase in pressure is due to the relatively diminishing size of the abdominal cavity caused by posttraumatic conditions such as external traumatic compression,[7] intraperitoneal bleeding and/or retroperitoneal hematoma,[6],[8] acute gastric dilatation, and intraperitoneal free air occupying space within the abdominal cavity.[8] In our case also, there was free intraperitoneal gas due to jejunal perforation which may lead to increase in IAP. This may cause acute appendicitis in our case, and it is also a very rare mechanism that may cause appendicitis.

Ramsook has discussed an indirect mechanism resulting in TA, triggered by a sudden increase of IAP during trauma.[9] According to this mechanism, a sudden increase in IAP may lead to an increased intracecal pressure followed by a rapid distention of the appendix. This may cause abrasion of the appendiceal mucosa together with a decrease in the appendiceal blood flow. He suggested that mucosal injury and decreased blood flow might result in appendicitis.

In review of the literature, there have been two different sets of criteria for the diagnosis of traumatic appendicitis. The first, by Fowler, states that to diagnose traumatic appendicitis, there should be no previous history of appendicitis attacks, the cause of the trauma and mechanism of injury should create a force capable of reaching the appendix, and the effects of trauma should be experienced immediately and merge into that of acute appendicitis. Traumatic lesions of the appendix should be operatively demonstrated and therefore must be superimposed by acute inflammation of the appendix.[9] Ramsook also had similar thoughts and proposed the diagnostic criteria as follows: (1) no history of abdominal pain before trauma, (2) there would be direct and violent blunt force to the abdomen of limited duration, and (3) progressive worsening of signs and symptoms that merge into clinical presentation of appendicitis, confirmed by surgical intervention.[2] According to both Fowler and Ramsook, our patient would fit the criteria of traumatic appendicitis. The jejunal perforation after blunt trauma abdomen can be explained by the following fact. The mechanism of injury ranges from mesenteric laceration due to compression and bowel rupture due to deceleration injury. This affects fixed segments such as the duodenum, duodenojejunal flexure, proximal jejunum, and terminal ileum.

Although rare, trauma continues to be a possible and very interesting cause of appendicitis that deserves to be in the differential diagnosis for the cause of worsening abdominal pain following BAT.

If clinical outlook suggests appendicitis in cases conservatively managed for BAT, physical examinations, abdominal ultrasonography, and/or abdominal computed tomography should be repeated for diagnosis of traumatic appendicitis. This approach will help to protect the patients against the complications of appendicitis that are likely to develop.


  Conclusion Top


Albeit a rare origin, trauma can be a cause for appendicitis as we show in our case study. To make this diagnosis, there are certain criteria that must be met. It should be kept in mind that children managed for severe BAT may develop appendicitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Toumi Z, Chan A, Hadfield MB, Hulton NR. Systematic review of blunt abdominal trauma as a cause of acute appendicitis. Ann R Coll Surg Engl 2010;92:477-82.  Back to cited text no. 1
    
2.
Fowler RH. The rare incidence of acute appendicitis resulting from external trauma. Ann Surg 1938;107:529-39.  Back to cited text no. 2
    
3.
Serour F, Efrati Y, Klin B, Shikar S, Weinberg M, Vinograd I, et al. Acute appendicitis following abdominal trauma. Arch Surg 1996;131:785-6.  Back to cited text no. 3
    
4.
Sharma AK, Vig S, Neades GT. Seat-belt compression appendicitis. Br J Surg 1995;82:999.  Back to cited text no. 4
    
5.
Diebel LN, Dulchavsky SA, Brown WJ. Splanchnic ischemia and bacterial translocation in the abdominal compartment syndrome. J Trauma 1997;43:852-5.  Back to cited text no. 5
    
6.
Schein M, Klipfel A. Local peritoneal responses in peritonities-clinical scenarios I: Peritoneal compartment responses and its clinical consequences. Sepsis 1999;3:327-34.  Back to cited text no. 6
    
7.
Sullivan KM, Battey PM, Miller JS, McKinnon WM, Skardasis GM. Abdominal compartment syndrome after mesenteric revascularization. J Vasc Surg 2001;34:559-61.  Back to cited text no. 7
    
8.
Saggi BH, Sugerman HJ, Ivatury RR, Bloomfield GL. Abdominal compartment syndrome. J Trauma 1998;45:597-609.  Back to cited text no. 8
    
9.
Ramsook C. Traumatic appendicitis: Fact or fiction? Pediatr Emerg Care 2001;17:264-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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   Abstract
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  Discussion
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