ISPUB.COM The Internet Journal of Surgery Volume 27 Number 1 1 of 5 Isolated Small Bowel Perforation After Blunt Abdominal Trauma: Report Of 2 Cases N Symeonidis, K Ballas, K Psarras, M Lalountas, S Rafailidis, T Pavlidis, A Sakantamis Citation N Symeonidis, K Ballas, K Psarras, M Lalountas, S Rafailidis, T Pavlidis, A Sakantamis. Isolated Small Bowel Perforation After Blunt Abdominal Trauma: Report Of 2 Cases. The Internet Journal of Surgery. 2010 Volume 27 Number 1. Abstract Isolated perforation of the small bowel after blunt abdominal trauma is infrequent and the diagnosis can be elusive. Although computerized tomography is the modality most commonly used, there is no consensus over the optimal diagnostic approach. Diagnostic difficulties result in delayed surgical treatment and eventually in increased morbidity and mortality. We report two cases of isolated small bowel perforation after blunt abdominal trauma in patients involved in car accidents. Seat belts were used in both cases. Thorough physical examination and immediate diagnostic radiology and laboratory workup failed to detect evidence of any intraabdominal injury. Deterioration of the clinical picture raised suspicion of small bowel perforation and the delayed surgical intervention resulted in postoperative complications and prolonged clinical course. INTRODUCTION The prior concern during blunt abdominal trauma (BAT) is injury of solid organs, which is mostly responsible for the resulting mortality. Hollow viscus injuries are much more uncommon compared to the non-hollow ones. It has been reported that small bowel is the most commonly injured hollow viscus and the third most commonly injured organ in BAT [1,2]. Serosal tears, intramural hematomas, mesenteric vessel injuries and transmural perforation or transection of the bowel are considered different types of small bowel injury [1]. Small bowel perforation (SBP) after BAT is an infrequent injury. A large multi-institutional study on blunt hollow viscus injury performed by the Eastern Association for the Surgery of Trauma indicate that after blunt abdominal trauma the incidence of small bowel injury and SBP is 1.1% and 0.3%, respectively [2]. Isolated SBP pose additional diagnostic difficulties. Firstly, since it is not associated with any other intraabdominal injury, it cannot be diagnosed incidentally during an emergency celiotomy. Secondly, although marked improvement in the quality of computerized tomography (CT) has been achieved over the last years, the false-negative rate of CT is still disturbingly high for SBP [3]. Thirdly, clinical presentation of SBP is usually vague and physical examination inconclusive so suspicion comes only when marked deterioration of the clinical status has been established. The aim of this study is to present two cases of isolated SBP caused by blunt abdominal injury treated during the last five years in our department and to emphasize the diagnostic and therapeutic considerations associated with this condition. CASE REPORT 1 A 47-year-old woman was admitted to the emergency department after a car accident. The patient reported that she was the driver of the car and had the seat belt on. She also complained of pain on her left anterior chest. Vital signs were normal (blood pressure 130/75mmHg, pulse rate 90/minute), a seat belt sign was found and left anterior chest tenderness with no crepitus. Abdominal palpation revealed mild diffuse periumbilical tenderness without guarding. Plain chest x-rays showed a 5 th left rib fracture with ipsilateral pneumothorax, which was treated with thoracostomy tube placement. Routine blood tests were normal. Due to the abdominal tenderness a computerized tomography (CT) scan was performed which detected no intraabdominal injury. After 24 hours of observation, the patient’s clinical status deteriorated as she complained of severe abdominal pain and the clinical examination revealed signs of generalized peritonitis. Upon laparotomy, a rupture on the antimesenteric border of the jejunum, 50cm distal to the ligament of Treitz, was found. No other injuries were detected and a small segmental resection of jejunum and end-to-end anastomosis was performed. On histology,