Abdominal Pain in a Collegiate Football Player

Abstract

Hx: A 23 y/o NCAA football player who was unable to catch his breath after being hit in the abdomen at practice. He continued for 10 more plays prior to reporting the injury. He stated that he had increasing LUQ pain and shortness of breath. PE: Pox 99%, HR 104, lungs CTAB but shallow. Abdomen: BS (+), TTP LUQ, no mass or rebound, Kehr’s sign (+). Evaluated in ER and released. Next morning: c/o LUQ and suprapubic pain, did not sleep well. Appetite and urination decreased, no N/V/D; afebrile; HR 90-100, BP 128/74, Pox 98%. Waves of diaphoresis; TTP suprapubic and LUQ areas. BS (+), no rebound. No rash or bruising. That afternoon: continued pain and urine retention; diaphoretic and intermittently pale with BP 148/94, HR 100, Pox 96%, afebrile, shallow breathing due to pain. DD: 1. Rib fracture 2. Splenic injury 3. Pancreatic injury 4. Small bowel injury 5. Traumatic ileus 6. Renal trauma 7. Left lung injury 8. Retroperitoneal hemorrhage TESTS/RESULTS: - US fast scan - WNL - Istat – Hgb and Cr WNL - Stat CT abd – only showed 12th rib fracture FINAL/WORKING Dx: Jejunum perforation Tx /OUTCOMES: 1. Transported to the ER. Fast scan US was normal. CT scan showed 12th rib fracture. Given IV dilaudid, toradol, Percocet for overnight pain. 2. Next morning reported urinary retention and decreased appetite which he felt due to the medication. Had an US which showed full bladder and no splenic injury. 3. D/c meds and gave IM toradol and PO tramadol for the pain. 4. No improvement and was admitted to the hospital for IV hydration and pain control, further lab testing, observation. 5. Pain continued into the night. Labs showed increased pancreatic enzymes and CPK. CXR and AAS showed B pleural effusion and possible free air under diaphragm. 6. Local surgeon consulted did not think there was free air but concerned with pancreatic injury. 7. Transferred to tertiary care center. 8. Observed in the SICU for a day and started declining in status. An MR cholangiogram ordered to evaluate the pancreatic duct but stopped due to the presence of free air. 9. Emergent exploratory laparotomy showed a jejunum perforation. Rresected and repaired. 10. Two days postop, taken back to OR for a leak at the repair site. 11. Small abscess developed under the diaphragm; treated percutaneously. 12. Currently doing great. Working out at pre-injury levels.