Intestinal Perforation In Children Research Articles

Post-operative Complications following Laparotomy for Typhoid Intestinal Perforation in Children: Experience in a Tertiary Hospital in Enugu, Nigeria

Post-operative Complications following Laparotomy for Typhoid Intestinal Perforation in Children: Experience in a Tertiary Hospital in Enugu, Nigeria

Morbidity and Mortality of Typhoid Intestinal Perforation Among Children in Sub-Saharan Africa 1995\u20132019: A Scoping Review

BackgroundTyphoid fever incidence and complications, including intestinal perforation, have declined significantly in high-income countries, with mortality rates <1%. However, an estimated 10.9 million cases still occur annually, most in low- and middle-income countries. With the availability of a new typhoid conjugate vaccine licensed for children and recommended by the World Health Organization, understanding severe complications, including associated mortality rates, is essential to inform country-level decisions on introduction of this vaccine. This scoping review summarizes over 20 years of the literature on typhoid intestinal perforation in sub-Saharan Africa.MethodsWe searched EMBASE, PubMed, Medline, and Cochrane databases for studies reporting mortality rates due to typhoid intestinal perforation in children, under 18 years old, in sub-Saharan Africa published from January 1995 through June 2019.ResultsTwenty-four papers from six countries were included. Reported mortality rates ranged from 4.6–75%, with 16 of the 24 studies between 11 and 30%. Thirteen papers included postoperative morbidity rates, ranging from 16–100%. The most documented complications included surgical site infections, intra-abdominal abscesses, and enterocutaneous fistulas. High mortality rates can be attributed to late presentation to tertiary centers, sepsis and electrolyte abnormalities requiring preoperative resuscitation, prolonged perforation-to-surgery interval, and lack of access to critical care or an intensive care unit postoperatively.ConclusionsCurrent estimates of mortality related to typhoid intestinal perforation among children in sub-Saharan Africa remain unacceptably high. Prevention of typhoid fever is essential to reduce mortality, with the ultimate goal of a comprehensive approach that utilizes vaccination, improvements in water, sanitation, and hygiene, and greater access to surgical care.

Catastrophic Healthcare Expenditure from Typhoid Perforation in Children in Nigeria.

Background: Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections. Methods: We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE. Results: There were 15 boys and 17 girls aged 2-15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3-93 days (mean 23 days). The average total medical cost was $452 (range $236-$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone. Conclusion: Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.

Enteric Fever Complicated by Intestinal Perforation in Children: A Persistent Health Problem Requiring Surgical Management.

Objective:To evaluate clinical presentation and surgical outcome in children with enteric perforation.Methods:A descriptive retrospective study was conducted in Department of Paediatric Surgery at National Institute of Child Health, Karachi from August 2016 and September 2019, in children 12 years of age and under with diagnosis of enteric perforation. Data about age, gender, duration of illness, hemodynamic status and baseline investigation on admission was reviewed. Details about patients operated early and those who required prolong resuscitation and were operated after 24 hours of admission, need for tube laparostomy, operative findings, type of surgical procedure performed and post-operative outcome were reviewed. Data was analyzed using SPSS version 22.Results:Ninety-seven patients, 60(61.85%) males and 37(38.14%) females were managed during the study period with age ranged from 3-12 years (mean 7.82, ± 2.94 years).and duration of symptoms ranged from 7-30 days (mean 15.56, ± 9.39days). High grade fever and abdominal pain were seen in all patients (100%). Pneumoperitoneum was noted in 71(73.19%) cases on X-ray abdomen. Fifty-one (52.57%) children were anemic and required blood transfusion before surgery. Seventy-one (73.19) patients were optimized and operated within 24 hours while 28(28.86%) cases required more resuscitation so tube laparostomy was done initially and operated after 24 hours. Seventy nine (81.44%) cases had single perforation, 14(14.43%) cases had multiple and four had sealed perforation. Primary repair of perforation was done in 37(38.14%) cases, while ileostomy in 65(76.01%) cases. Postoperatively wound infection was seen in 71(73.19%) cases, intra-abdominal collections in 31(31.95%) and burst abdomen in nine (9.27%) cases. Overall mortality was 12.37%. Till date in 47 patients (72.30%) reversal of stoma has been done.Conclusions:Enteric perforation in children presents usually with hemodynamic instability and sepsis due to prolong period of illness. Therefore, regardless of surgical procedure performed it is associated with high morbidity and mortality.

Impact of practice change on intestinal perforation risk for pediatric gastrojejunostomy tube placement

BackgroundGastrojejunostomy tubes (GJTs) have been associated with intestinal perforation in children <6 months or <6 kg. This study evaluated the impact of an institutional practice change recommending a new soft tip GJT for children <10 kg. MethodsWe performed a single-center review of GJT placements among children <10 kg before (1/1/2010–12/31/2013) and after (7/1/2014–12/31/2016) the practice change. Intestinal perforation, nasojejunal tube (NJT) for >30 days, and GJT replacement were assessed. ResultsSixty GJTs were placed in 35 children (54% male; 17.2±9.0 months old) after compared to 147 GJTs in 77 children (44% male, p=0.32; 14.1±11.8 months, p=0.08) before the practice change. Use of soft tip GJT was adhered to in 19 placements (32%). There were no intestinal perforations after the practice change (before: 6 (4.1%); p=0.11). NJT remained >30 days in 15 patients (65%) after the practice change (before: 13 (35%); p=0.02). Replacement was required for 53% with soft tip GJT and 18% with standard GJT (p=0.006). DiscussionA reduction in intestinal perforation with an institutional practice change may be explained by fewer GJT placements in high-risk children and longer length of NJT placement. Future protocols may consider age and size restrictions rather than alternative tube types. Type of studyTreatment study. Level of evidenceLevel III.

Childhood Typhoid Intestinal Perforation in Aba, Nigeria

Typhoid intestinal perforation is still prevalent in many low and middle income countries. This may be due to lack of potable water, poor refuse disposal and health education. This study is to evaluate the outcome of management of typhoid intestinal perforation in children at the Abia State University Teaching Hospital Aba Nigeria. This is a prospective study of children who were managed for typhoid intestinal perforation at the Paediatric Surgery unit, department of Surgery of the Abia State University Teaching Hospital Aba Nigeria from November 2016 to September 2018. Proforma was opened for demography, clinical features, investigation, site of perforation, type of surgery, complications and outcome. Data collected were analysed using SPSS computer software version 17 for proportions and percentages. Results: Sixty patients were seen over the sixteen months study period. Forty males and twenty females with a male to female ratio {2:1}. Their ages ranged from 3 years to 15 years with a mean age of 8.9 years. Fever, abdominal pain, vomiting and abdominal distension were the commonest clinical features in over 50% of patients. Doubled layer closure and resection and anastomosis of ileal segment were done in equal number of patients [20 patients each]. Surgical site infection was the most common complications in 50 [83.3%] of patients. Five patients died giving a mortality rate of 8.3%. Typhoid intestinal perforation is still a persistent scourge in low income countries. Morbidity is still high despite low mortality in this series. Early presentation, good nutrition and public health education will improve outcome.

PERFORATION PERITONITIS: A CASE STUDY.

Peritonitis is an emergency health condition that is life-threatening and requires urgent surgery. here we presented a case of perforation peritonitis for a 21 years old male. The patient suffered severe abdominal pain constant vomiting of what he eat, not bloody diarrhoea and he had moderate fever. Abdomen examination showed peritonitis. And the CT.abdomen examination showed a presence of peritonitis and few air pocket in rectosigmoid region and posterior to pancrease which mean that patient had peritonitis with pneumoperitoneum. The patient underwent surgery and stayed in the hospital for 7 days during which the patient\\\'s health improved and became healthy. Pavlidis, T. E. "Cellular changes in association with defense mechanisms in intra-abdominal sepsis."?Minerva chirurgica6 (2003): 777-781.‏ Meena, Laxmi Narayan, Sanchit Jain, and Prahlad Bajiya. "Gastrointestinal perforation peritonitis in India: A study of 442 cases."?Saudi Surgical Journal3 (2017): 116.‏ Ch, Biram, et al. "A Clinical Study of the Spectrum of Gastro Intestinal Perforation Peritonitis in Rural Southern East Rajasthan."?Journal of Universal Surgery2 (2017).‏ Prasad, N. Baba Guru, and KV Bhaskar Reddy. "A study of acute peritonitis: evaluation of its mortality and morbidity."?International Surgery Journal2 (2016): 663-668.‏ Bali, Rajandeep Singh, et al. "Perforation peritonitis and the developing world."?ISRN surgery2014 (2014).‏ Chakma, Sujit M., et al. "Spectrum of perforation peritonitis."?Journal of clinical and diagnostic research: JCDR11 (2013): 2518.‏ Coppolino, F. F., et al. "Gastrointestinal perforation: ultrasonographic diagnosis."?Critical ultrasound journalS1 (2013): S4.‏ Kolar, Mila, et al. "Free intestinal perforation in children with Crohn's disease systematic literature review and case report."?Journal of Pediatric Surgery Case Reports(2018).‏ Rohit, Dushyant Kumar, R. S. Verma, and Grishmraj Pandey. "Clinical study and management of peritonitis secondary to perforated peptic ulcer."?International Surgery Journal8 (2017): 2721-2726.‏ Ordonez, Carlos A., and Juan Carlos Puyana. "Management of peritonitis in the critically ill patient."?Surgical Clinics6 (2006): 1323-1349.‏ [Ameen Abdulrahman A kamal. (2018); PERFORATION PERITONITIS: A CASE STUDY. Int. J. of Adv. Res. 6 (Feb). 1527-1530] (ISSN 2320-5407). www.journalijar.com Ameen Abdulrahman A kamal

Free intestinal perforation in children with Crohn's disease

Abstract Background Free intestinal perforation in children with Crohn's disease (CD) is a rare, but serious complication that requires urgent surgical management. The incidence, contributing risk factors, diagnostic workup, and management strategies for these complex pediatric patients are not well established. Methods We present a recent case of free intestinal perforation in a patient with CD. In addition, a systematic review of the literature was conducted by searching the PubMed, Embase, Ovid, Scopus and Cochrane databases. Two authors independently extracted data, reviewed the abstracts, and assessed them for inclusion in the review. Results The literature review identified 21 pediatric patients documented in 14 publications; including our case, there are a total of 22 pediatric patients reported. The majority of patients presented with features of peritonitis. Perforation occurred early in the disease course (median 6.5 months), and was most commonly a single perforation in the ileum with active Crohn's disease (82%). Colonic perforation occurred in 18% of patients. All patients underwent urgent surgical management. Surgical approaches included resection of the diseased bowel segment with proximal diversion in eleven patients (50%), resection with primary anastomosis in 9 (41%) or direct suture repair in two (9%). Both patients who underwent simple primary repair developed post-operative complications. Conclusions Free intestinal perforation may occur at any age and stage of Crohn's disease. Three-dimensional imaging may be required to confirm the diagnosis. The management of free intestinal perforation in CD is surgical. This should involve resection of the involved segment with proximal diversion or resection with primary anastomosis in selected cases. Primary suture closure of the perforation is discouraged.

小児 SLE に合併した小腸穿孔の2症例

小児 SLE に合併した小腸穿孔の2症例

Predictors of intestinal perforation in children with typhoid fever

Typhoid fever is a major public health problem globally; the greater burden however occurs in the developing countries because of lack of potable water and proper waste management. The disease is associated with a high mortality rate especially in those with enteric perforation or intestinal hemorrhage. The goal of this study was to identify the clinical and laboratory factors that predicts the development of enteric perforation in children with typhoid fever. This study was a retrospective case-control analysis of children admitted for typhoid fever with or without enteric perforation over a three – year period in a newly established teaching hospital in southwestern Nigeria. Forty-seven children with typhoid fever and enteric perforation (cases) were compared with 94 controls (those with typhoid fever but without enteric perforation). Multivariate analysis using logistic regression was applied to all the factors that were initially significantly associated with enteric perforation. Male sex (Odd Ratio, OR = 3.10, p = 0.003); inadequate treatment (OR = 3.03, p

Host factors and typhoid fever-associated intestinal perforation in children in Nigeria

We compliment Nasir et al. [1] for their meticulous study on forecasters of mortality-associated typhoid with an intestinal perforation in Nigeria. The contribution by different host factors, such as MHC and human leukocyte antigen (HLA), that might have been responsible for the occurrence of a high proportion of intestinal perforations in typhoid fever in Nigerian children merits an exploration, and this could be assessed through studies on confirmed cases with and without intestinal perforations. A genetic association in humans between typhoid fever and MHC class II and III genes was evident in individuals with blood culture-confirmed typhoid fever and control subjects from two distinct geographic locations in southern Vietnam [2]. HLA-DRB1 and HLA-DQB1 alleles {the gene that encodes tumor necrosis factor (TNF)-alpha (TNFA [-238] and TNFA [-308], the gene that encodes lymphotoxin-alpha, and alleles of the TNF-alpha microsatellite HLA-DRB1*0301/6/8, HLA-DQB1*0201-3, and TNFA*2 (-308)} were associated with susceptibility to typhoid fever [2]. On the other hand, HLA-DRB1*04, HLA-DQB1*0401/2, and TNFA*1 (-308) were associated with disease resistance [2]. Furthermore, initial studies on the role of genetic factors in susceptibility to non-alcoholic fatty liver disease point toward an important role of human leukocyte antigen in the pathogenesis of non-alcoholic fatty liver disease [3]. Apart from pulsed field-gel electrophoresis typing (PFGE) of isolates from cases with intestinal perforation [1], their genotypic characterization would be valuable to rule out the presence of abnormal flagellar antigenic components responsible for the intestinal perforations in Nigeria. A S. typhi strain carrying the flagellar antigen variant H1-j was associated with acute appendicitis in a Chinese woman in Hong Kong [4].

Intestinal Perforation in Children - A Clinico-pathologic Evaluation of 67 Cases

Purpose: Intestinal perforation is a rare entity in paediatric age group when compared to adults. This entity has attracted little attention and the causes have not been elaborated. A clinico pathologic analysis of intestinal perforation in this age group was conducted to determine the underlying etiopathogenesis. Methods: The retrospective study included 66 children with intestinal perforation admitted to in-patient department of our hospital, over a period of one year, from January 2010 to December 2010. The case files of all the patients were retrieved and demographic and clinical data was recorded. The histopathology sections of all cases were re-reviewed and analysed. Results: Mean age of the patients ranged from 1 day to 12 years. There were seven neonates and twelve infants. The male to female ratio was 2.3:1. Children presented with symptoms of acute abdominal pain (most common), diarrhoea, or absence of meconium passage. Clinical evidence of peritonitis was present at initial evaluation in 22 (33%) children. Radiological evidence of perforation (pneumoperitoneum) was present in 40 (60.6%) cases with a further 12 (18%) cases showed dilated bowel loops or air-fluid levels. Thus, the radiographs were diagnostic in only 78% cases. The mean time from admission to laparotomy was 17 hours. The most common site of perforation was distal ileum followed in descending order by appendix, jejunum and caecum. A single perforation was noted in 60 cases, while multiple intestinal perforations were present in seven patients. The most common cause of perforation in neonates was necrotising enterocolitis. After the neonatal period infective causes were more common including tuberculosis, amoebiasis and fungal infection (most common being mucormycosis). In eighteen (27%) cases no specific cause of perforation could be detected. Conclusion: Intestinal perforation in infants and children can have a very varied aetiology. Clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in significant diagnostic delay. Further, early diagnosis of infective causes followed by prompt treatment could prevent perforation, thus significantly reducing morbidity and mortality in these children.

Typhoid intestinal perforation under 5 years of age

Typhoid intestinal perforation is an important cause of morbidity and mortality in many developing countries. The peculiar features in children <5 years old need to be recognised in order to improve outcome. To determine the characteristic pattern and outcome of typhoid intestinal perforation in children under 5 years of age in south-east Nigeria. Comparative analysis of 83 children with typhoid intestinal perforation between January 2001 and December 2006 at the University of Nigeria Teaching Hospital, Enugu. There were 22 (26.5%) children <5 years of age and 61 (73.5%) >5 years. In the younger children, the predominant presentation was fever, vomiting and abdominal tenderness, and in the older children it was fever, abdominal pain and distension. Features of peritonitis were present in only 54.5% aged <5 years compared with 90.2% of the older children (p<0.001). The average number of perforations in the under-5s was 2.1 (range 1-4) and >1.3 (range 1-3) in the older children (p<0.01). The types of operative procedure (simple closure and segmental bowel resection) were similar in both groups. Post-operative complications were not significantly different in the two groups and included surgical wound infection, prolonged ileus, pulmonary infection, wound dehiscence, re-perforation, intra-abdominal abscess and incisional hernia. There were nine (40.9%) deaths in the <5s and 12 (19.7%) in the >5s (p<0.05). Typhoid intestinal perforation in children <5 is associated with atypical presentation and high mortality. A high index of suspicion will ensure earlier presentation and might improve outcome.

Typhoid intestinal perforation in children in Ilorin: Salmonella versus the surgeon: Who is winning the race?

Typhoid intestinal perforation in children in Ilorin: Salmonella versus the surgeon: Who is winning the race?

Typhoid intestinal perforation in children: a continuing scourge in a developing country

Typhoid intestinal perforation is a principal cause of morbidity and mortality affecting both adults and children. This study aims to evaluate the pattern of typhoid intestinal perforation and outcome of its management in Nigerian children. The records of consecutive children managed for typhoid intestinal perforation at Juth, between 1996 and 2005 have been reviewed. There were 184 children (M:F = 1.04:1), with a mean of 5.8 years (range 4 to 15 years). More than a half (62.5%) of the patients were in the 5-6 year age group. The incidence peaked in April-May, and November-December. Increased incidence of typhoid perforation was observed between 2002 and 2005. All patients presented with the classic features of typhoid enteric perforation. Hypokalaemia and anaemia were common at presentation. Only 75 (40.6%) patients had operation within 24 h of perforation. The types of surgery included simple excision of the edges of the peroration and closure (74.5%), wedge resection and closure in (14.5%), segmental resection with primary end-to-end anastomosis (3.6%) and right hemi-colectomy with ileo-colic or ileo-transverse anastomosis. Wound infection and dehiscence, anastomotic breakdown with faecal fistula, intra peritoneal abscesses and chest infections were the main post operative complications. The overall mortality rate was 22.8 (42). Excision and simple closure was associated with the least incidence of anastomotic breakdown and operation time. The incidence of typhoid intestinal perforation is on the increase at our institution. Early limited surgery provides optimal results.

Factors effecting morbidity in typhoid intestinal perforation in children.

To determine the factors affecting morbidity in patients with typhoid intestinal perforation (TIP), 42 patients who had been operated upon for TIP between 1990 and 2000 were reviewed. The average age was 10.4 years, the male-to-female ratio 2.5/1. The mean interval from admission to operation was 6 h. Twenty-three children had multiple perforations. Primary closure (PC) was performed in 55% of the patients, ileostomy in 26%, and resection with anastomosis (RA) in 19%. Parenteral nutrition (PN) was available for 22 patients for an average of 9 days. Postoperative complications occurred more commonly in patients with delayed admission and/or severe peritonitis. Hospitalization was shorter and the postoperative complication rate lower in patients who received PN and in those who underwent ileostomy. None of the patients developed an enterocutaneous fistula. The 2 deaths (4.8%) resulted from overwhelming sepsis. The most significant factors affecting morbidity were prolongation of perforation-operation interval and severe peritonitis. No operative procedure is likely to be the best in all cases; therapy should be individualized. Ileostomy appears to be an effective procedure, particularly in patients with severe abdominal contamination and delayed presentation. The use of PN in addition to standard medical and surgical therapy in patients with TIP may be beneficial.

Factors associated with intestinal perforation in children's non-typhi Salmonella toxic megacolon.

To evaluate the risk factors for intestinal perforation in children with toxic megacolon caused by non-typhi Salmonella infection. During an 11-year period we reviewed the records of children treated for non-typhi Salmonella infection. All of the subjects had positive stool culture for non-typhi Salmonella and were treated with intravenous ceftriaxone during hospitalization. Clinical data reviewed included demographic features, clinical manifestations, laboratory findings, radiologic findings, microbiology, therapeutic effect of hydration and rectal tube placement and the operative findings. Patients with toxic megacolon were defined as those having toxic appearance, diarrhea, high fever (>39 degrees C) and marked colon dilatation with maximal diameter > 1.5 times the width of the vertebra body of the first lumbar spine (L1-VB). To define the risk factors for patients with toxic megacolon complicated by intestinal perforation, patients were divided into two groups for analysis: P group, those complicated with intestinal perforation; and NP group, those without intestinal perforation. Differences in age, sex, severity of diarrhea, duration of fever, hemogram and its differential, culture, stool analysis, serum C-reactive protein (CRP), electrolytes, maximal colon diameter, medical therapy and timing of rectal tube insertion between the two groups were analyzed. Statistical analyses were conducted with chi square tests and multiple logistic regression. A total of 75 patients (P group, 27 patients; NP group, 48 patients) ages 4 months to 6 years were evaluated. With chi square analysis 7 variables were found to be significantly associated with intestinal perforation: age >1 year; fever >5 days; ratio of immature to total neutrophils >20%; serum CRP >200 mg/l; colon diameter >2.5 times the width of L1-VB; inadequate early hydration; and delay in rectal tube insertion. With multivariate analysis age >1 year, serum CRP >200 mg/l and colon diameter >2.5 times of width of L1-VB, inadequate early hydration and delay in rectal tube insertion were the most significant factors associated with intestinal perforation. Identification of patients with toxic megacolon associated with non-typhi Salmonella infection at risk for further intestinal perforation is possible. Early effective fluid resuscitation and rectal tube insertion may be helpful to prevent the occurrence of intestinal perforation.

Intestinal perforation in children.

There were 102 cases of intestinal perforation seen in children at the Department of Paediatric Surgery at S.S. Hospital, Varanasi during a 3 year period. Enteric (typhoid) perforation (29%), intussusception (15%) Ascaris lumbricoides infestation (9%) and appendicitis (9%), which are rarities in the reported literature, were the major causes of intestinal perforation. Radiological evidence of pneumoperitoneum was seen in 88% of patients. The majority of cases in this study were older than 5 years of age (48%). Peritoneal fluid culture revealed Escherichia coli and Klebsiella to be the most common aerobic micro-organisms, while Bacteroides fragilis, Clostridia and Peptostreptococcus were the most frequent anaerobes. The overall mortality rate was high (19%).

Intestinal perforation due to blunt trauma in children in an era of increased nonoperative treatment.

Over the past decade, nonoperative management of most pediatric blunt abdominal trauma has emerged as accepted practice. It is possible that treatment of associated hollow visceral disruption might be missed or delayed because of this nonoperative approach. In a review of all cases of intestinal perforation from blunt trauma seen over the past 6 years, we found 12 cases of intestinal disruption in more than 600 cases of significant blunt trauma. Child abuse caused eight cases and four were motor vehicle related (MVR). Seven of eight battered children had a delay of more than 48 hours from injury to hospital presentation. Three of four MVR patients had an 18-hour delay from injury to operation. Ten of 12 patients survived. The two children who succumbed were both battered and were moribund and unstable when first seen and failed to respond to aggressive stabilization and surgery. Serial physical examinations, contrast radiographic studies, and peritoneal lavage were the most helpful diagnostic modalities. There were no significant complications and no patient required more than one operation (except for ostomy closure). All surviving patients are well at followup and seven of ten have been followed for more than 3 years; two are not yet 1 year from surgery and one is lost to followup. Several principles have emerged from this review: 1) motor vehicle trauma and child abuse are the major etiologic factors in childhood blunt trauma; 2) accurate and rapid diagnosis of intestinal perforation in children is difficult; 3) recovery in the presence of stable vital signs can be expected, even with the long delays; and 4) abused children must be carefully evaluated for abdominal trauma.