GASTROINTESTINAL PERFORATIONS IN CHILDREN - A CONTINUING CHALLENGE TONONOPERATIVE TREATMENT OF BLUNT ABDOMINAL-TRAUMA

The present trend towards conservative management of hemodynamically s table pediatric trauma patients may be increasing the risk of delay in the diagnosis of traumatic hollow viscus perforations (HVP). The purp ose of this study is to determine whether there is a delay in the diag nosis of HVP because of expectant management, A survey of factors lead ing to diagnostic delay was also made and the value of current diagnos tic tools were reevaluated. In 1,283 trauma admissions between 1980-19 94, 34 patients were operated for HVP caused by blunt abdominal trauma , Sites of perforation were; stomach (four), duodenum (five), jejunum (12), ileum (nine), and jejunum/ileum (four). Signs of peritoneal irri tation were positive in 32 of 34 patients, There was free air in only six of: 24 abdominal roentgenograms. Free peritoneal fluid without sol id organ injury was detected in only four out of 13 patients with ultr asound, Peritoneal lavage was diagnostic in eight of nine patients. Ti me from admission to operating room averaged 24 +/- 4.1 (mean +/- stan dard deviation) hours, Eleven patients died after the operation mostly because of accompanying head injury, Only two of the deaths were the result of sepsis originating from the perforated bowel. There is an ap parent delay in the diagnosis of traumatic HVP in this series, Signs o f peritoneal irritation are the most consistent findings of HVP after blunt abdominal trauma in children, Persistence of abdominal signs ind icates peritoneal lavage, which has a high diagnostic sensitivity for HVP compared to other diagnostic modalities.