Delayed Small Bowel Obstruction after Blunt Abdominal Trauma

Abstract

Blunt abdominal trauma may produce acute intra-peritoneal injury requiring laparotomy for intestinal perforation or vascular compromise. Intra-abdominal pathology from blunt trauma may be delayed. Delayed small bowel obstruction after blunt abdominal trauma is a rare clinical entity whose pathogenesis has not been clearly established. We present a case of delayed small bowel obstruction due to stricture formation in the distal duodenum over the spine. The patient is a 56 year-old female who presented to the emergency room with a 5 day history of nausea and vomiting. Initial laboratory testing revealed only pre-renal azotemia consistent with dehydration from persistent vomiting. An abdominal computed tomographic scan was obtained which revealed a distal duodenal obstruction of unclear etiology. There was marked dilatation of the stomach and duodenum. An enteroscopy was performed, which demonstrated a large amount of fluid in the stomach and duodenum with normal-appearing mucosa. However the enteroscope could not be passed beyond the distal duodenum due to extrinsic compression. The duodenal mucosa was normal. A small bowel series was then performed. The stricture in the distal duodenum was 2 cm in length and exhibited delayed passage of contrast. After no improvement with one week of nasogastric suction, the patient was referred for surgery. At laparotomy, over the spine, there was circumferential fibrosis of the duodenum at the junction with the jejunum. Due to the location of the stricture with adjacent vasculature, a gastro-jejunostomy was performed. This case demonstrates the rare entity of post-traumatic delayed small bowel obstruction. The location of the delayed obstruction over the spine in a thin woman suggests a similar anatomic risk as seen in patients with traumatic pancreatitis. Whereas a ductal disruption occurs in traumatic pancreatitis, an inflammatory process related to the blunt trauma over the spine may result in fibrosis and progressive narrowing of the bowel. Clinicians should be aware of delayed post-traumatic obstruction and focus the evaluation of the bowel to that overlying the spine.