Pediatric emergency medicine trisk 3196 3196

The development of fever or worsening peritonitis on serial physical examinations should alert the examining physician to the possibility of bowel perforation Plain radiographs of the abdomen demonstrate free intra-abdominal air in only 30% to 50% of cases Similarly, pneumoperitoneum or leakage of gastrointestinal contrast is only rarely seen on the CT scan Most perforations or transections of bowel are found during laparotomy or laparoscopy which the surgeon has chosen to perform because of advancing peritonitis or unexplained persistent fever Management depends on the site and extent of structural injury A significant percentage (up to 25%) of hollow visceral injuries may not be apparent on the initial CT scan of a child with blunt injury Therefore, evaluating the mechanism of injury should lead to a high index of suspicion for this type of injury A significant lap belt sign is a harbinger of possible bowel injury Similarly, unexplained free fluid (e.g., not associated with a solid visceral injury) in the abdomen on CT scan should be very carefully evaluated and consideration should be given for laparoscopy or laparotomy Late Presentations of Intra-Abdominal Trauma Some children with abdominal trauma not have evidence of intra-abdominal pathology on initial evaluation but may return days or weeks later with abdominal distention and/or pain, persistent emesis, or hematochezia In particular, three injuries are characterized by late presentations: (i) pancreatic pseudocyst (previously discussed), (ii) duodenal hematoma, and (iii) hematobilia Intramural duodenal hematoma is an uncommon injury that results from a direct blow to the epigastrium (blunt force delivered by a small-diameter instrument such as a broom handle or the toe of a boot) or from rapid deceleration (e.g., in the lap belt syndrome) and may cause partial or complete gastric outlet obstruction Bleeding into the wall of the duodenum causes compression and resultant symptoms of intestinal obstruction, including pain, bilious vomiting, and gastric distention Diagnosis is made by ultrasonography, contrast upper gastrointestinal study, or a CT scan revealing the “coiled-spring sign” or a soft tissue mass in the bowel wall Injury of the pancreas must be suspected when duodenal hematoma is considered Nonoperative management includes nasogastric decompression and parenteral nutrition for up to weeks Rupture of the gallbladder is rare and is almost always associated with severe blunt trauma to the liver It will almost always be accompanied by severe peritonitis Likewise, hematobilia is associated with hepatic trauma and is a result of pressure necrosis from an intrahepatic hematoma or direct injury to the biliary