Sport-related Jejunal Rupture.

Abstract

Introduction Serious injury as a result of abdominal trauma in collision sport is relatively rare. The most commonly reported injuries are to solid organs, such as the spleen and liver (1). Splenic injury risk is elevated in many medical conditions such as infectious mononucleosis (2). The hollow organs of the digestive tract are less commonly injured in collision sport and reports of such injuries are limited to case reports (3–8). The reported incidence of hollow organ injury in trauma ranges from 1% to 8.5% (9). The surgical literature more commonly reports this type of injury, typically in accidents that involve blunt trauma with bicycle handle bars in children (10,11). Motorcycle and motocross accidents leading to bowel injury also are reported. A recent case of bowel injury associated with splenic and pancreatic laceration also was reported (12). In the following case series, we report two cases of abdominal trauma in collision sport leading to bowel injury. Case 1: Jejunal Rupture in an Ice Hockey Player A 19-year-old male collegiate ice hockey player presented for evaluation after he was checked from behind and had his abdomen driven into the boards by an opposing player. The injury occurred in front of his bench, where there is no glass. He stepped over the boards and sat on the bench where he was evaluated by the Certified Athletic Trainer and Team Physician on site. Once in the athletic training room, he complained of acute left upper quadrant (LUQ) pain. Pain was 7/10, sharp, and radiating to his left shoulder. He was found to be very pale and diaphoretic. He was in obvious pain and distress. He was afebrile with a heart rate of 84 bpm, blood pressure of 92/68 mm Hg, respiratory rate of 18 to 20 bpm, and pulse oximetry of 100%. The cardiovascular examination revealed normal heart sounds without murmur. Lungs were clear to auscultation bilaterally. His abdominal examination was soft with LUQ tenderness. He was nondistended, had normal bowel sounds, and did have involuntary guarding. Given this examination, he was transferred by ambulance to the emergency department (ED). A focused assessment with sonography in trauma (FAST) was performed in the ED that was normal. Computed tomography (CT) of his abdomen revealed a small subcentimeter splenic contusion. The bowel at that time was read as normal. Due to the splenic contusion and his continued pain, the decision was made to keep him overnight for observation. Eight hours after his initial presentation, he had an abrupt increase in pain and became tachycardic. His WBC increased from 9,000 to 19,000. The decision was made to take him for exploratory laparotomy, where he was found to have a small laceration on the antimesenteric side of the jejunum approximately 30 cm from the ligament of Treitz, which was repaired at that time. He was treated with prophylactic piperacillin-tazobactam and fluconazole for 3 d postoperatively. Following the surgery, the patient remained in the hospital for 6 d, which were uneventful, and then discharged home. One month later, he was seen in follow-up by trauma. His examination was unremarkable. His injury was late in the season and as such he did not return to play for the remainder of the season. At his 2 month surgical follow-up, he was cleared to participate without restriction for the following hockey season. He was successful in returning to full unrestricted hockey the following season. Case 2: Jejunal Rupture in a Football Athlete A 23-year-old collegiate football athlete was struck in the LUQ by an opposing player’s elbow during routine, limited contact practice drills. He participated in 10 more plays but then stopped due to progressive LUQ abdominal pain. He complained that he felt like the wind was knocked out of him and had vague bilateral shoulder discomfort. On examination his oxygen saturation was 99% on room air, heart rate 104, and blood pressure 130/78. In general, he was in obvious pain, but in no acute distress. He was talking normally. Neck revealed no jugular venous distention (JVD), midline trachea, and no subcutaneous crepitus. Cardiovascular examination was mildly tachycardic without murmur. Lungs were clear bilaterally, but with shallow breaths. Abdomen was nondistended with normal active bowel sounds. There was LUQ tenderness without rebound. No masses were palpated. With the history of blunt LUQ trauma and a positive Kehr’s sign (referred pain to the tip of the left shoulder), there was concern for possible splenic injury. As such, he was immediately transported to the community hospital’s emergency department (ED). While in the ED, he had a normal FAST scan, normal I-stat evaluation of hemoglobin and creatinine, and a CT scan was performed that was read as normal except for a nondisplaced 12th rib fracture. He was given intravenous (IV) and oral pain medication and advised to follow up with his team physician the next day. On the evening of the injury, he slept poorly with persistent abdominal pain. The next morning, he reported worsening LUQ pain and new suprapubic pain. He denied hematuria, but had limited urination since the ED visit. His appetite was decreased, but he denied nausea, vomiting, or diarrhea. He believed the pain medications were contributing to his discomfort and symptoms. On re-evaluation in the athletic training clinic, vitals were as follows: afebrile; HR, 90–100 bpm; blood pressure 148/94 mm Hg; Pox, 98%. In general, he was stoic, in no acute distress, but was in obvious pain, and had occasional waves of diaphoresis. Neck had no JVD. Cardiovascular was mildly tachycardic without murmur. Lungs were still clear with shallow breaths. Abdominal examination revealed normal bowel sounds, suprapubic fullness, and abdominal tenderness greater in suprapubic area than the LUQ. There was suprapubic guarding. There was mild tenderness over the left 12th rib. Extremity examination was normal. Skin revealed no rash or bruising. The decision was made to admit the athlete to the hospital for IV pain control, IV fluid resuscitation, and further studies. While making these arrangements, a FAST scan was repeated in the athletic training clinic to determine if urgent surgical intervention was required. It showed no obvious spleen injury, blood collection or fluid pocket, but there was a substantial amount of urine in the bladder. In the hospital, laboratories showed a WBC count of 4.8 with 80% neutrophils. Hemoglobin was 17.4; blood urea nitrogen, 31; creatinine, 2.4; amylase, 728 with lipase 1074. Chest x-ray and acute abdominal series radiographs showed the left 12th rib fracture, small bilateral pleural effusions due to diaphragmatic irritation, and a question of free air under the diaphragm. Due to the concern for bowel rupture and traumatic pancreatic injury, surgery was consulted. The surgeon felt that bowel rupture was unlikely due to the mechanism of injury. However, due to the concern of traumatic pancreatitis, he agreed that the patient should be transferred to a tertiary care center, where he was initially observed in the intensive care unit. Due to continued decline, a magnetic resonance cholangiopancreatography was ordered which was terminated midprocedure due to recognition of significant free fluid and intraperitoneal air. The patient was then emergently taken to the operating room where a jejunal perforation was identified and treated with partial jejunal resection. Unfortunately, having developed sepsis due to the small bowel perforation, his postoperative course was complicated initially by anastomotic leak. Subsequently, he developed a small subdiaphragmatic abscess which was treated successfully with percutaneous drainage. After several weeks in the tertiary care center, he was discharged home. He gradually rehabilitated, and by 2 years postinjury, was able to participate in sport at a high level and even attended a professional football training camp. Discussion Blunt trauma resulting in bowel perforation is a rare but real risk in collision and contact sports. In both of these cases, the diagnosis of bowel injury was delayed. This is consistent with cases previously presented (1). Perry et al. presented a case of a rugby player with a complete transection of his jejunum. This athlete was able to finish playing and did not present for medical care until 4 h after his injury. In the trauma surgery literature, delayed presentation of hollow viscus injury is not uncommon (6,9,11). In both cases presented here, the initial CT scan demonstrated grossly normal appearing bowel. In the case of the ice hockey player, a review of the game video revealed that his stick was in front of him as he hit the boards. One possible explanation for his injury might be that the stick compressed his bowel against his spine. This would be a similar mechanism to what is seen with handlebar trauma. Fortunately, the patient was observed overnight because of a grade 1 splenic injury to the lower pole. Several hours later, after developing acutely worsening pain and a leukocytosis, he was taken to the operating room, which revealed the jejunal laceration. In the case of the football player, imaging studies were again normal initially. Contact in this case was relatively routine. In both cases, it appears that the bowel injury may have evolved over time. In addition, CT scan imaging on initial presentation can be challenging and is often not sensitive for identifying bowel perforation (13). Abdominal plain films in an upright position can be used to identify free air in the abdomen after perforation, but often lack sensitivity early in the process and are less sensitive than CT, so are often not performed (13,14). Given the commonly observed delayed presentation, a high index of suspicion must be maintained for the potential of bowel injury after blunt abdominal trauma. Observation and close follow-up with serial abdominal examinations are prudent in these cases. Repeat FAST scan 12 to 24 h after presentation also has been shown to aid in the identification of bowel injury (15). While serial FAST examination is not the intent of this scan, this may be a fast and reasonable way to re-evaluate abdominal trauma, especially if the clinical picture is changing. Often, as in the case of the hockey player, the rapidly changing picture may make surgical exploration the best option because imaging is not sensitive enough to rule out a perforation in the setting of a worsening abdominal examination. It is felt that the mechanism for bowel injury from blunt trauma may be a result of shearing forces from two opposing surfaces (16). In sport, the two surfaces are likely the object hitting the abdomen and the patient’s spine. Theories for a delayed presentation include temporary localized ischemia that evolves over hours into a full thickness perforation. Another theory is that, due to a lack of bleeding, there is an absence of peritoneal signs and symptoms (11). The Table is a review of the reported sports related jejunal ruptures. It is important to note that none of the reported jejunal ruptures were identified by initial imaging. It does appear that a number of the patients had intraperitoneal air or fluid on initial imaging. The time to presentation ranges from hours to days.Table: Reported cases of bowel injury.In regard to return to play considerations, both of the athletes in these cases were cleared for return following clearance from their trauma surgery and sports medicine teams. The athlete, the athlete’s family, athletic training staff, and coaching staff should all be involved in this decision at some point during the process. Objective criteria for return to play would be that the athlete demonstrates healing from the surgery, no pain at rest or with activity, tolerating a full diet, and successful functional progression to full noncontact training. The length of time required for healing often may be at the discretion of the trauma surgeon based on the specific injuries and operation(s) required. The Table highlights that previous case reports have not discussed return to play. In the reported cases a clearance to return to activity was given at 6 to 8 weeks, which accounts for surgical healing time in uncomplicated cases. Ultimately, the goal is a safe return to play and prevention of recurrent injury. Conclusions Blunt abdominal trauma leading to serious abdominal injury is a rare, but very real risk in collision and contact sports. Sports medicine physicians and professionals should maintain a high index of suspicion for bowel injury, especially if the athlete is worsening or not progressing despite negative initial imaging. Once the injury is identified and treated surgically, the return to play process should include a multidisciplinary approach to ensure a safe return and prevention of recurrent injury.