Total intestinal obstruction due to traumatic submucosal jejunal hematoma: A case report

Abstract

Introduction and importance

Blunt abdominal trauma can result in various injuries, including intestinal hematomas causing obstruction. Traumatic submucosal jejunal hematomas are rare, especially in children, with bicycle handlebar injuries being a potential cause. Prompt recognition and appropriate imaging are crucial for accurate diagnosis and management.

Case presentation

A 10-year-old boy presented with delayed abdominal pain, vomiting, and absence of bowel movements following blunt abdominal trauma from a bicycle handlebar injury. Abdominal CT scan confirmed a submucosal jejunal hematoma, leading to exploratory laparotomy and duodenojejunostomy.

Clinical discussion

Bicycle handlebar injuries, although seemingly minor, can cause significant internal damage, especially in children. Delayed symptoms pose a diagnostic challenge, necessitating a high index of suspicion and imaging modalities like CT scans for timely intervention.

Conclusion

This case underscores the importance of considering traumatic submucosal jejunal hematomas in children with blunt abdominal trauma, particularly from bicycle handlebar injuries. Surgical intervention may be necessary in cases of complete intestinal obstruction, emphasizing the need for prompt diagnosis and treatment.

Highlights

• •Blunt abdominal trauma can cause submucosal hematomas leading to intestinal obstruction.
• •Bicycle handlebar injuries in children often present with delayed abdominal symptoms.
• •Traumatic submucosal jejunal hematomas in children are rare and difficult to diagnose.
• •Abdominal CT scans are crucial for identifying internal injuries causing obstruction.
• •Surgical intervention may be required to treat complete intestinal obstruction in children.

1. Introduction

Blunt abdominal trauma is a significant cause of morbidity and mortality in children, accounting for approximately 25 % of major trauma cases [4]. Traumatic submucosal jejunal hematomas are rare, particularly in children, with few documented cases in the medical literature [2]. Although submucosal duodenal hematomas are more common, traumatic submucosal jejunal hematomas can also lead to severe complications, such as intestinal obstruction. Bicycle handlebar injuries, while seemingly minor, can cause significant internal damage due to concentrated force at the point of impact. Children are at higher risk due to their lighter weight, thinner abdominal walls, and less protective musculature [5].

This manuscript was prepared following SCARE guidelines.

2. Case report

A 10-year-old boy presented to our hospital with complaints of middle abdominal pain and bilious vomiting for nine days. The abdominal pain was intermittent, with episodes of increased severity. The vomiting was consistently bilious and occurred each time the patient ate or drank. He also had no bowel movements during this period. The patient's parents mentioned that he fell from his bicycle and hit his stomach on the handlebars. Initially, the injury seemed minor, and the patient did not seek medical attention immediately.

However, as symptoms worsened over ten days, the parents decided to take him to a primary healthcare facility. During an initial examination, there were no significant findings in the abdominal X-ray, and the patient was given pain medication. Due to persistent symptoms, the patient was referred to a secondary hospital for further evaluation and assessed for additional tests, including laboratory tests, chest X-ray, and abdominal CT scan. The CT scan revealed a focal dilatation in the distal duodenum with lumen narrowing and a solid lesion intraluminally, suggestive of an intramural hematoma (Fig. 1). Given these findings and the worsening clinical presentation, the patient was referred to our hospital for surgical evaluation.

Fig. 1.

Abdominal CT scan showed submucosal jejunal hematoma.

On physical examination, the patient was conscious with typical vital signs, but his abdomen showed decreased bowel sounds and tenderness in the middle abdominal region. No fecal staining was found in the digital rectal examination. Laboratory tests revealed elevated white blood cells (WBCs), low sodium and potassium levels, and elevated liver enzymes, suggesting systemic inflammation and possible internal injury. Based on these findings, the decision was made to proceed with exploratory laparotomy.

A transverse incision through the left upper quadrant of the abdomen was made due to suspicion of a pancreatic cyst. We identified a submucosal hematoma in the jejunum, causing complete obstruction due to pressure on the lumen (Fig. 2). This finding confirmed the CT scan results, indicating a traumatic origin [3]. Incision of the serosa and submucosa, followed by evacuation of the clot, was performed. Despite efforts, complete evacuation of the hematoma is unattainable, leading to the decision to proceed with a duodenojejunostomy bypass. Resection and anastomosis weren't possible due to the extensive nature of the hematoma, which extended into the duodenum, making it challenging to explore. The duodenojejunostomy bypass was performed from the incision point on the jejunum after the evacuation of all the clot intraluminal. The procedure was successful, and the patient was monitored closely in the postoperative period.

Fig. 2.

A) Dilatation of the jejunum distal to the area of the ligament of Treitz (arrow); B) jejunotomy performed, revealing a hematoma in the submucosa of the posterior jejunum (arrow).

Following the surgery, we evaluate the patient clinically and observe signs and symptoms such as fever and other infection manifestations. The patient experienced a slow recovery, with complications including abdominal distention due to intestinal paralysis. Enteral feeding was delayed until day eight postoperative, and the patient had to be gradually reintroduced to solid food. This cautious approach was necessary to prevent further complications and to allow the gastrointestinal tract to heal. We also performed a follow-up ultrasound examination to evaluate the hematoma. The follow-up ultrasound did not reveal any complications, such as an enlarging hematoma or signs of leakage. The patient was discharged on day twenty postoperatively without further complications.

3. Discussion

This case report highlights the unique nature of traumatic submucosal jejunal hematomas resulting from bicycle handlebar injuries in children. While handlebar injuries are common, they often lead to delayed and nonspecific symptoms, causing them to be overlooked [1,3,6]. The force exerted by the handlebars can cause significant internal injuries despite minimal external signs [6]. This case underscores the importance of early diagnostic imaging, especially with persistent or worsening symptoms, to identify and address potentially severe complications like submucosal hematomas.

In this case, the total intestinal obstruction required surgical intervention, but there are instances where non-surgical management may be appropriate, particularly in hemodynamically stable patients with mild symptoms. Conservative management, including bowel rest, nasogastric aspiration, and intravenous fluids, has succeeded in several case series [6,7]. However, surgery may be the best course of action when complete obstruction is suspected, as in our case.

The delayed onset of symptoms after bicycle handlebar injuries can lead to misdiagnosis or delayed treatment. Therefore, healthcare professionals should maintain a high level of suspicion and use appropriate diagnostic tools, such as CT scans, to ensure accurate diagnosis and timely intervention [5]. Imaging modalities like ultrasound, CT, and MRI play a crucial role in diagnosing intramural hematomas. CT is often considered the imaging modality of choice due to its ability to differentiate hematoma from perforation and assess the extent of the injury [6,7].

Furthermore, the literature suggests that intramural hematomas can also result from anticoagulation therapy, coagulation disorders, or endoscopic procedures. This broadens the differential diagnosis in patients presenting with similar symptoms and highlights the importance of a thorough medical history and appropriate imaging studies [7].

In our case, the use of a transverse incision and the decision to perform a duodenojejunostomy bypass rather than resection and anastomosis were influenced by the challenging location of the hematoma and the need to ensure complete evacuation of the clot [8,9]. Postoperative care included close monitoring for signs of infection and complications, with follow-up ultrasound examinations to evaluate the residual hematoma. This approach helps in early detection and management of any potential issues post-surgery.

Overall, this case contributes to the understanding of traumatic submucosal jejunal hematomas and underscores the need for timely diagnosis and intervention to prevent severe complications and ensure optimal patient outcomes.

4. Conclusion

This case report demonstrates the serious risk of bicycle handlebar injuries in children and their potential to cause severe intra-abdominal trauma. Symptoms' delayed and nonspecific presentation requires careful evaluation and early diagnostic imaging. Surgical intervention may be necessary in cases of total intestinal obstruction due to submucosal hematomas. Proper diagnosis and treatment are crucial for optimal patient outcomes.

Consent

Informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval in case report was not needed from our hospital, Harapan Kita National Woman and Children Hospital, Jakarta, Indonesia. Consent from patients and family is enough for publication.

Funding

Padjadjaran University.

Guarantor

Samuel Amosilo Santoso Kesek.

Research registration number

This study did not require registry.

CRediT authorship contribution statement

• Samuel Amosilo Santoso Kesek: study concept, data collection, writing the paper.

• Dikki Drajat Kusmayadi: corresponding author, reviewing the manuscript.

• Kozzy: data analysis, interpretation of data.

• Karina Priskila Setiawan: data collection and editing.

Declaration of competing interest

All authors have no conflicts of interest to declare.