Open Journal of Clinical Diagnostics, 2013, 3, 30-32 OJCD doi:10.4236/ojcd.2013.32007 Published Online June 2013 (http://www.scirp.org/journal/ojcd/ ) A rare presentation of silent gastric perforation in quadriplegic patient Suryapratap Singh Tomar 1* , Saranjeet Singh Bedi 2 , Akheel Mohammad 3 1 Department of Neuro, Trauma and Spine Surgery, Narayana Medical College and Hospital, Nellore, India 2 Department of Neurology, Narayana Medical College and Hospital, Nellore, India 3 Department of Cranio-Maxillofacial Surgery, Narayana Medical College and Hospital, Nellore, India Email: * dr.suryapratap_singh_tomar@yahoo.com Received 26 April 2013; revised 31 May 2013; accepted 10 June 2013 Copyright © 2013 Suryapratap Singh Tomar et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Traumatic cervical spinal cord lesions are highly su- sceptibility to produce life threatening complications like respiratory failure, cardiac failure and gastroin- testinal complications. We are presenting a case of traumatic cervical cord injury with quadriplegia, presented with chief complaints of constipation with abdominal distention and altered sensorium. After detailed examination and history, patient diagnosed as case of post traumatic cervical spine with inciden- tal finding of gastric perforation and managed surgi- cally in emergency. Keywords: Gastric Perforation; Cervical Spinal Cord Injury; Viscus Perforation 1. INTRODUCTION Gastrointestinal complications after acute spine injury are not uncommon but misdiagnosed and frequently le- thal. Cervical spine cord injury (CSCI) affects the physi- ology of the gastrointestinal system [1]. Gastric motility changes in cervical spine injury because of dissociation of duodenal motility with manifestation of autonomic dysreflexia [2]. Surgical and medical treatment of trau- matic spinal cord injury is well proved in literature but it may present with complication like perforation of hollow viscus due to stasis of gastric acid, disruption of mucosal and bicarbonate barrier and bacterial overgrowth [3]. 2. CASE HISTORY A 60 years old male was admitted in the ward as fol- low-up with the chief complaints of traumatic quadri- paresis of two weeks duration. He was bedridden for last 3 years with urinary catheter. His general and systemic examination was unremarkable. Neurologically, higher mental functions and cranial nerve examination were normal. There was hypotonia in all limbs. He had sensory loss below C4-5 and power grade was 1/5. Deep tendon reflexes were mildly de- creased. Babinski signs were positive bilaterally. X-ray cervical spine was normal. MRI cervical spine showed traumatic cord compression (C3-5 level) with signal intensity changes. His baseline blood investiga- tions were within normal limit. Patient was managed conservatively and was on NSAID’S, Baclofen with low dose steroid. After 24 hr of admission in hospital, patient developed hypotension, feeble pulse and weakness. He was drowsy but arousable. Per abdomen examination reveals mild distension and chest examination was normal. Based on these findings, spinal shock was suspected and medical management with proton pump inhibitors, steroid and intravenous fluid started. The patient gradually became alert, pulse and blood pressure became normal. After 48 hours, he developed massive abdominal dist- ension. Per abdominal examination revealed distension, diffuse tenderness and rebound tenderness over the ab- domen. On auscultation of abdomen, bowel sound was absent and shifting dullness was absent on percussion. Routine investigation revealed high leukocyte count with 16,800/cumm. Supine X-ray chest and abdomen were normal (Figure 1). Patient was unable to stand up for erect abdominal X-ray and facility of computer tomogra- phy of abdomen was not available, so we decided to pro- ceed with abdominal X-ray in lateral decubitus, which showed free air in the peritoneal cavity (Figure 2). A diagnosis of perforation of hollow viscous with peritoni- tis, electrolyte imbalance and septicemia was made. With all pre-operative preparation, patient underwent emergency laparotomy and a pyloric perforation was * Corresponding author. Published Online June 2013 in SciRes. http://www.scirp.org/journal/ojcd