06 September 2024: Articles
Pediatric Pyloric Transection: An Unusual Injury Following Blunt Abdominal Trauma
Unusual clinical course, Challenging differential diagnosis, Diagnostic / therapeutic accidents, Management of emergency care, Clinical situation which can not be reproduced for ethical reasons
Saud Aljadaan1ADE*, Rahaf Y. Ardah2ABDEF, Raseel A. Alsubaie2ABDEF, Suliaman Alaqeel1EDOI: 10.12659/AJCR.944624
Am J Case Rep 2024; 25:e944624
Abstract
BACKGROUND: The pediatric population, due to its distinct anatomy and physiology, often presents with unique mechanisms of trauma, leading clinicians to encounter diverse and sometimes unexpected injuries. Whether these injuries result from blunt or penetrating trauma, they may involve intra-abdominal organs in pediatric patients. Additionally, there are occasional occurrences where injuries affect rare sites such as the pylorus in an isolated manner within this age group. Clinicians must be prepared to address a wide range of injury patterns to ensure optimal outcomes for pediatric patients experiencing trauma to intra-abdominal structures such as the pylorus.
CASE REPORT: We report a 19-month-old boy who presented with abdominal pain, crying, and repeated vomiting of gastric contents after a wardrobe fell on his upper torso. His vital signs were stable except that he was tachycardiac. Upon investigation, abdominal computed tomography (CT) revealed pneumoperitoneum, free peritoneal fluid, and inflammatory changes in the intestinal wall, suggesting hollow viscus injury. Exploratory laparotomy was performed, and complete transection of the pyloric area of the stomach was identified. The pancreatic and biliary ducts were intact. On postoperative day 5, an upper gastrointestinal (UGI) contrast study prior to initiating oral feeding was done and showed normal findings with no contrast leakage. His postoperative course was unremarkable.
CONCLUSIONS: Isolated pyloric injuries following blunt trauma are rare with no known case reports in pediatric age group. High morbidity and mortality rates can result from traumatic gastrointestinal injuries including the involvement of pylorus. Therefore, accurate diagnosis and prompt management are essential for an improved outcome.
Keywords: Pylorus, Child, Adverse Childhood Experiences
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.
Figures
Figure 1.. Chest and abdominal X-ray showing suspected pneumoperitoneum but no clear signs of pneumoperitoneum. Figure 2.. Abdominal CT scan with IV contrast showing pneumoperitoneum (red star in lung window). Figure 3.. Intra-operative finding of transected pylorus forceps holding one edge of the transected pylorus. Figure 4.. Intra-operative finding of primarily repair transection with Graham patch. Figure 5.. Postoperative contrast study showing no leak.References:
1.. Paltiel HJ, Barth RA, Bruno C, Contrast-enhanced ultrasound of blunt abdominal trauma in children: Pediatr Radiol, 2021; 51(12); 2253-69
2.. Cintean R, Eickhoff A, Zieger J, Epidemiology, patterns, and mechanisms of pediatric trauma: A review of 12,508 patients: Eur J Trauma Emerg Surg, 2023; 49(1); 451-59
3.. Rothrock SG, Green SM, Morgan R, Abdominal trauma in infants and children: Prompt identification and early management of serious and life-threatening injuries. Part I: Injury patterns and initial assessment: Pediatr Emerg Care, 2000; 16(2); 106-15
4.. Gaines BA, Intra-abdominal solid organ injury in children: Diagnosis and treatment: J Trauma, 2009; 67(2 Suppl.); S135-39
5.. Holcomb GW, Murphy JD, Ostlie DJ: Ann R Coll Surg Engl, 2019; 101(8); 621
6.. Acker SN, Kulungowski AM, Error traps and culture of safety in pediatric trauma: Semin Pediatr Surg, 2019; 28(3); 183-88
7.. Szadkowski MA, Bolte RG, Seatbelt syndrome in children: Pediatr Emerg Care, 2017; 33(2); 120-25
8.. Balasubramanian G, Vijayakumar C, Anbarasu I, Isolated rupture of duodenum following blunt trauma abdomen: Report of a case of avulsion of pylorus: International Surgery Journal, 2017; 4(8); 2845-47
9.. Lai CC, Huang HC, Chen RJ, Combined stomach and duodenal perforating injury following blunt abdominal trauma: A case report and literature review: BMC Surg, 2020; 20(1); 217
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