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Delayed colonic perforation in blunt abdominal trauma

bensonblues at comcast.net bensonblues at comcast.net
Tue Apr 11 07:04:58 BST 2006


Rob,
I am intrigued by your case. [ 31 yo wf mvc, c/o only R hip pain. No abd pain or tenderness on exam. CT abd pelvis with IV contrast only positive for acetabular fracture. 4 days after trauma begins to conplain of abdominal pain. Gets pelvis fixed same day. 3 days later CT scan without contrast c/w ileus. 1 day later free air in abdomen. Intraoperatively find R colonice perforation with large deserosalized area. What is the differential on the etiology of the delayed perf.  Not alot of literature out there on this. Hematoma versus vascular injury? Thanks Rob Wagner, M.D. rwag63 at yahoo.com ]

I have a few questions: Was the colon perf in an area anatomically contiguous to the acetabular fracture? Did bony fragments cause the problem, or was the force of impact so great that the colon slammed into the pelvis, bruising and devitalizing it? An acetabular fracture is a pelvic fracture, and the most common cause of death 48 hours after injury here is sepsis. Was the patient receiving prophylactic antibiotics (as recommended for pelvic fracture) during the postop week, possibly partially treating the sepsis resulting from the perforation? The initial serosal hole had to be small, or, it formed over time from necrosing bowel. Otherwise, wouldn't an abscess be present? Was there any fever? Did the orthopd do something during the pelvic repair? Probably not, but you got to think about it. Over a week, serial exams, WBC, and lactate should have alerted you something was up. Madam Curie's angels should have payed special attention to the area and picked up something, one would think from reading Walt and Wilson. But, the antibiotics may have delayed the CT diagnosis of the perforation by delaying abscess formation.
DB


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