Rare Isolated Jejunal Injury Following Blunt Abdominal Trauma

Anurag Roy; Arun Kumar M; Kshitij Jyoti; A Saravana Santhosh; Vitesh Popli

doi:10.17479/jacs.2024.14.3.122

Abstract

Blunt trauma to the abdomen can result in various injuries which are potentially fatal if not promptly recognized and treated. Mechanism of injury, anatomical location, patient demographics, and clinical profile play crucial roles in diagnosis and management. The article presents 2 cases illustrating the challenges, and successful management of isolated jejunal injuries, and highlight the significance of early recognition and surgical intervention. These injuries are rare and there needs to be a high index of suspicion, especially in cases with atypical presentation. The cases in this article underscore the critical role of early surgical intervention in achieving optimal recovery and reducing the morbidity and mortality associated with isolated jejunal injuries. Clinicians need to consider the possibility of small bowel perforation following apparently trivial injuries, and employ a comprehensive approach to managing abdominal trauma.

Keywords: abdomen, injuries, trauma

Introduction

Blunt trauma to the abdomen can result in a wide range of injuries, including isolated jejunal injuries [1–5]. These injuries are relatively rare but can be potentially fatal if not recognized and treated promptly [1,2,5]. Therefore, it is crucial for clinicians to be aware of the possibility of isolated jejunal injuries in patients presenting with abdominal pain following blunt trauma. The mechanism of injury and the specific anatomical location of the trauma play a crucial role in the outcome of abdominal injuries including isolated jejunal injuries. It is important to consider the patient’s demographic characteristics and clinical profile to effectively diagnose and manage such injuries [1–3,5].

Understanding the specific characteristics of abdominal injuries is also essential in providing comprehensive care. This includes utilizing diagnostic tools such as the Extended-Focused Assessment with Sonography in Trauma protocol and performing a thorough evaluation including a diagnostic laparotomy when necessary [1–3]. Jejunal injuries, though not so common in blunt abdominal trauma, can also have a delayed presentation leading to challenges in timely diagnosis and treatment. Therefore, clinicians should maintain a high level of suspicion and consider the possibility of isolated jejunal injuries even in cases where the mechanism of injury is trivial or the clinical presentation is atypical [4,6,7].

It is imperative for clinicians to remain vigilant and consider the possibility of isolated jejunal injuries in patients presenting with abdominal pain following blunt trauma, focusing on thorough evaluation and prompt management to ensure optimal patient outcomes [8].

Case Report

1. Case 1

A 52-year-old male, with no known comorbidities presented to the Surgical Outpatient Department with gradually progressive pain over his left lower abdomen and with a history of trauma to the left lower abdomen whilst working on machinery 2 days prior to presentation. The pain was acute in onset, with progressive intensity, and of a dull-aching character which was localized to the left iliac fossa. There was no history of associated nausea, vomiting, constipation, or obstipation. Clinical examination revealed stable vitals with erythema over the left iliac fossa with localized tenderness and guarding. The rest of the abdomen was soft, and bowel sounds, although present, were sluggish in regularity. He was admitted and further evaluation was arranged. However, by that evening, he had developed a high-grade fever with worsening abdominal pain and generalized guarding (Table 1, Figure 1).

Ultrasonography of the abdomen revealed free fluid in the pelvis with diffuse wall thickening of the bowel loops in the pelvis and the left inguinal region. He was immediately taken up for an emergency laparotomy which revealed a small jejunal perforation 60 cm from the duodeno-jejunal (DJ) flexure with 1.2 L of bile-stained fluid in the abdomen and pus flakes all over the jejunal loops. However, the rest of the bowel was essentially normal and no other solid organ injuries were noted. The identified jejunal perforation was repaired primarily (Figures 2 and 3).

The postoperative period was uneventful. The patient was started on oral feeds by postoperative Day 2 and discharged home on the 8^th postoperative day.

2. Case 2

A 31-year-old male man, with no known comorbidities, presented to the Emergency Department with severe pain in his abdomen of 4 hours duration, following blunt trauma to the abdomen caused by the handlebar of a motorcycle. The pain was acute at onset, progressive in intensity, and of a dull aching character. Initial examination revealed normal vitals. Head to toe examination revealed multiple abrasions over his face, extremities, and right iliac fossa. Per-abdominal examination revealed generalized tenderness with guarding and boardlike rigidity. However, bowel sounds were present. The Pelvic Compression test was negative and the external genitalia were normal. He was further evaluated using an X-ray scan of his erect abdomen which showed free air under his right hemidiaphragm (Figure 4). The rest of the lab parameters were within the normal limits.

After the initial resuscitation the patient was taken for an emergency exploratory laparotomy. Intraoperative findings revealed 2 liters of hemobilious intraperitoneal fluid and with a complete transection of jejunum about 45 cms from the DJ flexure (Figure 5). The patient underwent a primary end-to-end anastomosis of the jejunum. The postoperative period was uneventful. He was started on oral feeds by postoperative Day 3 and discharged on postoperative Day 10.

Discussion

Isolated jejunal injuries, following abdominal trauma, can present with atypical signs and symptoms, making them challenging to diagnose. These injuries may present with delayed symptoms and nonspecific clinical signs necessitating a high index of suspicion from health care workers. Early intervention and surgical repair are critical in achieving positive outcomes for patients with isolated jejunal injuries. The rarity and nonspecific nature of presentation with a jejunal perforation after a trauma which appears to be trivial emphasizes the importance of careful evaluation and consideration in symptomatic patients. It is essential to recognize the potential severity of isolated jejunal injuries, even in cases where the trauma may initially appear minor [1–3].

Isolated jejunal injuries following blunt trauma abdomen are relatively rare but can have serious consequences if not recognized and treated promptly [1,9]. They often present with nonspecific symptoms such as abdominal pain, tenderness, and distension making diagnosis challenging [10]. Furthermore, diagnostic procedures such as ultrasonography and computed tomography (CT) may not be readily available in resource-constrained settings, highlighting the importance of clinical evaluation and suspicion in jejunal injury cases [11,12].

The patients in this case report presented at a peripheral hospital where CT was not available. In such cases, early surgical intervention is crucial for optimal patient outcomes. In the context of increasing road traffic accidents, it is important for clinicians to be aware of the possibility of isolated jejunal injuries in patients with abdominal pain following blunt trauma, even if the mechanism of injury does not appear to be severe [13]. Therefore, a high index of suspicion, thorough clinical evaluation, and prompt surgical intervention are essential in managing isolated jejunal injuries and preventing potential complications or adverse outcomes. Timely recognition and management of isolated jejunal injuries in patients with abdominal trauma, regardless of the severity of the mechanism of injury, is essential for achieving favorable patient outcomes [14]. Therefore, it is important for clinicians to be vigilant and consider the possibility of a jejunal injury even in cases where the mechanism of injury may appear trivial or unsuspicious, as early intervention can lead to improved recovery and reduced mortality rates [1,14,15].

The clinical evaluation in both cases was instrumental in guiding the subsequent management. In Case 1, the patient’s presentation with gradually progressive pain in the left lower abdomen which initially led to conservative management. However, the subsequent development of a high-grade fever and worsening of pain prompted emergency surgical intervention, ultimately revealing a jejunal perforation. Similarly, in Case 2, the presence of board-like rigidity and generalized abdominal tenderness with guarding, along with the finding of free air under the right hemidiaphragm on X-ray of the erect abdomen, expedited the decision for an emergency exploratory laparotomy. Although the World Society of Emergency Surgery guidelines suggests cross sectional imaging like CT and serial CT scans for patients presenting with blunt trauma abdomen, to rule out any solid organ injury, it was not possible in these cases as they were managed at a peripheral center where CT was not available, and also, the patient’s condition deteriorated such that transfer to a more specialized hospital for treatment was not possible.

The utilization of diagnostic modalities such as X-ray imaging and ultrasound underscore the importance of comprehensive evaluation in cases of suspected abdominal trauma. The cases in this report highlight the need for a multifaceted approach to diagnostic evaluation, integrating clinical assessment with the appropriate imaging techniques to accurately identify and manage isolated jejunal injuries.

The surgical management in both cases involved immediate intervention to address the jejunal injuries identified. In Case 1, an emergency laparotomy revealed a small jejunal perforation 60 cm from the DJ flexure. Similarly, in Case 2, an emergency exploratory laparotomy resulted in the identification of a complete transection of the jejunum. These cases highlight the critical role of surgical intervention in isolated jejunal injuries. The prompt recognition of the injuries and the subsequent surgical repair would have significantly contributed to favorable postoperative outcomes. The successful management of these cases emphasizes the importance of early surgical intervention in achieving optimal patient recovery and reducing the associated morbidity and mortality.

Cases of isolated jejunal injuries following abdominal trauma present a unique diagnostic and management challenge due to their atypical presentations and potential for delayed symptoms. Health care workers should maintain a high index of suspicion for internal abdominal injuries, particularly in trauma patients with seemingly minor external manifestations. Moreover, the instances of favorable outcomes following timely recognition and surgical repair underscore the necessity for prompt and comprehensive management strategies in cases of suspected isolated jejunal injuries.

Early recognition, and treatment of isolated jejunal injuries, regardless of the severity of the mechanism of injury, are crucial for improving patient outcomes, and preventing complications. Therefore, a comprehensive approach to managing abdominal trauma, encompassing a high index of suspicion, early surgical intervention, and a detailed understanding of the clinical profile and presentation of isolated jejunal injuries, is essential to minimize the risk of adverse outcomes. In conclusion, this case report serves as a reminder to clinicians of the possibility of small bowel perforation following seemingly trivial injuries.

The cases presented serve as illustrations of the critical importance of early recognition, comprehensive diagnostic evaluation, and prompt surgical intervention in managing isolated jejunal injuries following abdominal trauma. These cases provide valuable insights into the nuanced clinical presentations and management paradigms for such injuries, ultimately emphasizing the pivotal role of proactive and vigilant healthcare practices.

Acknowledgment

The authors would like to thank the anesthesiologists, intensivists, radiologists and nursing staff for the prompt assistance and high grade of professional competence that led to favorable outcome in both cases.

Notes

Author Contributions

Conceptualization: AR. Methodology: AR, AKM, and KJ. Formal investigation: AR, AKM, ASS, and VP. Data analysis: AR, ASS, and VP. Writing original draft: AR. Writing - review and editing: AR, AKM, and KJ.

Conflicts of Interest

The authors declare that they have no competing interests.

Funding

None.

Ethical Statement

No ethical dilemmas.

Data Availability

All relevant data are included in this manuscript.

Figure 1

An X-ray of the abdomen (erect) showing gas under the diaphragm.

Figure 2

A jejunal perforation measuring 60 cm from the duodeno-jejunal junction with surrounding pus flakes.

Figure 3

A primary repair of the jejunal perforation.

Figure 4

An X-ray of the abdomen (arrow) showing free gas under the right hemidiaphragm.

Figure 5

A complete transection of the jejunum.

Table 1

Investigations on Admission

Parameter	Admission day
Haemoglobin	15.3 gm/dL
Total leukocyte count	19,100/mm³
Differential leukocyte count	Neutrophils-92% Lymphocytes-05% Eosinophils-02% Monocytes-01%
Urea/creatinine	35/1.18 mg/dL
Total serum bilirubin	1.8 mg/dL
Na⁺/K⁺	139/4.1 meq/mL

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