Pediatric Pyloric Transection: An Unusual Injury Following Blunt Abdominal Trauma

Introduction

Trauma is a leading cause of mortality in children [1]. To the best of our knowledge, pyloric injury due to blunt abdominal trauma is rare, and only 1 case has been reported in the English literature. This case report describes a rare occurrence of pyloric transection after blunt trauma in a 19-month-old boy who underwent successful surgical intervention.

Case Report

The patient was a previously healthy 19-month-old boy. While playing in his room, a wardrobe fell on his upper torso. At the time of injury, the only concern was abdominal pain. Initially, he was taken to a local clinic, was found to be stable and was discharged without any further workup. Twenty-four hours after the injury, he presented to our Emergency Department. He was crying, in pain, and with repeatedly vomiting of gastric contents. His vital signs were stable except that he was tachycardiac. His abdomen was tender with generalized guarding. The rest of his examination was unremarkable. An abdominal and chest X-ray was suspicious for pneumoperitoneum (Figure 1). Abdominal computed tomography (CT) revealed pneumoperitoneum, free peritoneal fluid, and inflammatory changes in the intestinal wall, suggesting a hollow viscus injury (Figure 2). Based on the clinical and radiological findings, the patient was taken to the operating room for exploratory laparotomy. There was complete transection of the stomach at the area of the pylorus, with no perforation of the small or large bowel (Figure 3). The pancreas and biliary duct were intact. A circumferential pyloric injury was identified and repaired with simple interrupted absorbable sutures and a Graham patch (Figure 4). His postoperative course was unremarkable. An upper gastrointestinal (UGI) contrast study on postoperative day 5 revealed that the stomach, pylorus, and duodenum were normal in size and had normal morphology, and there was no evidence of leakage (Figure 5). Oral feeding was then started, and the patient was discharged home.

Discussion

The mechanism of abdominal injury can be divided into blunt and penetrating trauma. Blunt trauma includes impacts or blows and collisions with objects or people. Blunt abdominal injuries are considered the third most frequent cause of pediatric trauma mortality, and injuries to the head and extremities are the next most common causes [2]. The most frequent causes of traumatic intra-abdominal injury in children are bicycle accidents, sports injuries, and non-accidental trauma [3]. The liver and spleen continue to be the 2 most frequently injured organs, but injuries to the stomach, including the pylorus, are considered to be unusual [4].

Transection of pylorus in this case can be explained by the following factors: (1) Blunt abdominal injuries usually occur in areas of the bowel that are fixed within the abdominal cavity. The duodenum, proximal jejunum, sigmoid colon, and rectum are among the regions at or near the retroperitoneum that most frequently sustain traumatic intestinal injuries. Since these fixed parts are immobile, they are less likely to be displaced in the event of a blunt abdominal impact. The duodenum is a portion of the intestine that is fixed to the retroperitoneum, and the duodenum is close to the pylorus, making the pylorus vulnerable to damage, as observed in our case [5]. (2) Pediatric patients have a thin abdominal wall, allowing more blunt force to be transmitted to the intra-abdominal organs including the pylorus. Consequently, the mechanism underlying pyloric transection involves compression of the pylorus near a fixed portion of the bowel – between the wardrobe and the patient’s vertebral column, causing a sudden increase in intraluminal pressure of the pylorus leading to its transection [5–7].

In this case, the patient presented 24 hours after the injury, with tachycardia, abdominal tenderness, and suspicious findings of pneumoperitoneum on abdominal/chest X-ray. An abdominal CT scan was performed to further evaluate the extent of the injury, which revealed pneumoperitoneum, free peritoneal fluid, and inflammatory changes in the intestinal wall, suggesting a hollow viscus injury. The patient was taken to the operating room for an exploratory laparotomy as a result of these findings. To the best of our knowledge, the only case similar to our case was published in 2017 in an adult with similar injury, in which a 19-year-old male presented with a ruptured duodenum following a blunt abdominal injury. He was hit by a ball while playing cricket [8]. Similar to our patient, his vital signs were normal. In contrast to our patient, free air under the diaphragm was clear on chest X-ray. Due to the X-ray findings, the patient underwent laparotomy without undergoing a CT scan. Similar to our patient, the pancreas/biliary system was intact, and no hematoma/retroperitoneal fluid was found. In their reported case, there was a pyloric avulsion and a full circumferential rupture of the first part of the duodenum, which was managed with primary repair of the avulsion with a Graham patch along with a jejunostomy feeding tube. In our patient, only primary repair with Graham patches was performed, and he was discharged after he could tolerate an oral diet.

Conclusions

In conclusion, pyloric transection is very rare, and to our knowledge, no cases have been reported in pediatric patients. High rates of morbidity (27.1%) and mortality (5.3–30%) have been reported for traumatic proximal gastrointestinal injuries, especially if not detected early [9]. Accurate diagnosis of pyloric injuries can be challenging, particularly in blunt traumas. Therefore, physicians should be able to appropriately evaluate children who have sustained a forceful abdominal injury and be aware of the possibility of pyloric transection as part of their differential diagnosis to provide appropriate and prompt management to these patients.