BLUNT INTESTINAL INJURY IN CHILDREN - DIAGNOSTIC AND THERAPEUTIC CONSIDERATIONS

Objectives: To identify computed tomographic (CT) findings in children who have experienced blunt trauma and who have known intestinal injur ies and to correlate these findings with the findings of the initial p hysical examination. Design: A retrospective review of children (aged <18 years) known to have an intestinal injury as a consequence of blun t trauma. Setting: A university-affiliated children's hospital with a level I pediatric trauma center. Patients: Children younger than 18 ye ars who were admitted for examination of injuries or for management of complications related to intestinal injuries. Interventions: Clinical and radiographic evaluation and laparotomy for intestinal injuries ot her than duodenal hematoma. Main Outcome Measures: The identification and correlation of relevant findings during the physical examination, on the CT scan, and during surgery. The assessment of intervals from i njury to diagnosis and intervention and the description of associated injuries. Results: Twenty-two patients sustained intestinal injuries a s a result of blunt trauma. Most (15) of the patients were passengers injured in motor vehicle crashes; 14 of these patients were wearing se at belts. Focal blows to the abdomen from bicycle handlebars, hockey s ticks, or falls onto blunt objects were implicated in the remaining pa tients. For 19 of the 22 patients, the initial physical examination wa s conducted at Cardinal Glennon Children's Hospital, St Louis, Mo, and 18 of the 19 patients underwent a concurrent CT evaluation. Peritonit is was found in 5 of these 18 patients. Tenderness on physical examina tion was noted in 9 of the 18 patients (tenderness was not noted in 3 patients, and 1 patient had unreliable examination findings due to a c ervical spinal cord injury). Computed tomographic findings of pneumope ritoneum and extravasation of enteral contrast material were uncommon but diagnostic (in 5 patients). Free fluid in the pelvis in the absenc e of a solid organ injury, bowel wall thickening, and fluid-filled loo ps of bowel were more frequently useful signs of possible intestinal i njury (in 9 of the 18 patients) and led to earlier exploration when us ed in conjunction with physical examination as an indication for surge ry. Most injuries were treated with segmental resection or suture repa ir, but enterostomies were required in 2 patients. Complications tie, the need for enterostomy and fascial dehiscence) were seen as a result of late or missed diagnosis, which could occur as late as 4 to 6 week s after injury as intestinal obstruction due to stricture. Conclusions : The initial physical examination findings and CT evaluation can inde pendently identify the presence of intestinal injury in approximately 25% of cases. In the remainder of cases, the awareness of the more sub tle findings of bowel injury on a CT scan can complement the physical examination findings and potentially lead to a more timely interventio n for bowel injury.