Case reports 65

of 26 children had mesenteric haematomas alone. No specific figure is given for those with bowel perforation (Kakos et al., 1971).

The mechanism of injury is usually by direct compression of the bowel against the vertebral body (Williams and Sargeant, 1963) and the Japarotomy findings of retroperi- toneal bruising as in our case would seem to confirm this.

Clearly, the key to successful management of these patients is early diagnosis and prompt laparotomy. The rarity of small bowel injury in these situations makes it easy to overlook and the clinician should have a high index of suspicion in these cases.

Goldberg B. et al. (1988) Injuries in youth football. Paediafrics 81,

255. Holt R. W., Wolf G. T. and France P. E. (1976) Rupture of the

jejunum secondary to blunt trauma in a football player. South. Med. J. 60, 281.

Kakos G. S., Grossfield J. L. and Morse T. S. (1971) Small bowel injuries in children after blunt trauma. Ann. Surg. 174, 238.

Murphy C. P. and Drez D. (1987) Jejunal rupture in a football player. Am. ]. Sports Med. 15, 184.

Nicholas J. A., Rosenthal P. and Gleim G. W. (1988) A historical perspective of injuries in professional football.]AMA 260,939.

Williams R. D. and Sargent F. T. (1963) The mechanism of intestinal injury in trauma. J. Trauma 31, 288.

References Paper accepted 7 April 1992.

Bergquist D., Hedelin H., Karlsson G. et al. (1982) Abdominal injuries from sporting activities. Br. J. Sporfs Med. 16, 76.

Bonilla K. B. and Bowers W. F. (1960) Traumatic rupture of the proximal jejunum. Am. 1. Surg. 100, 731.

Requests for reprinfs should be addressed fo: Mr N. Williams, Department of Surgery, Leicester Royal Infirmary, Leicester LEl

5WW, UK.

Gastric rupture from blunt trauma: two unusual presentations

J. D. Knottenbeltl, S. Van As’ and S. Volschenk’ ‘Trauma Unit and 3urgical Intensive Care Unit, Groote Schuur Hospital, Cape Town, South Africa

Introduction

Blunt gastric rupture is rare; Brunsting and Morton (1987) could find only 67 cases in the English literature since 1930. Mortality and morbidity in the reviewed cases were high (47 per cent). We present two survivors of this unusual condition, each of whom had interesting features.

Case reports

Close 1 A 24.year-old man was knocked down by a car and was brought into the trauma unit resuscitation area with a depressed level of consciousness and fracture of the right femur. On examination blood pressure was 120150 mmHg, pulse 112/min and haemoglo- bin level 12.5 g/d]. He was noted to have abrasions to the left frontotemporal region, with no CSF leak and the Glasgow Coma Score was initially assessed at 10/15, rising to 15/15 within 10 min of arrival. Chest examination was normal with no fractured ribs clinically. The abdomen was soft and undistended, with no rebound, tenderness or guarding. The right femur was clinically fractured in the midshaft, but there was no neurovascular deficit.

The patient was initially intubated to protect the airway because of the depressed level of consciousness and I litre of crystalloid given via peripheral line. Arterial blood gas analysis (ABG) (pH, 7.27; Pco,, 4.74 kPa; PO,, 31.6 kPa; Std bicarb, 17.0; Base excess, - 8.8) revealed a moderately severe metabolic acidosis with normal respiratory parameters. Serum urea and electrolytes were within normal limits. Urine obtained at catheter- ization showed the presence of microscopic haematuria but was

<<“I 1993 Butterworth-Heinemann Ltd 0020-1383/93/010065-02

otherwise normal. A nasogastric tube was inserted and 30 ml of normal-looking stomach contents returned. Radiography con- firmed a normal cervical spine and chest, and revealed a minor pelvic fracture (pubic rami), apart from the obvious fracture of the femur. The ABG was repeated 30 min later, showing a persistent acidosis in spite of the patient being warm, well-perfused and passing adequate urine (pH, 7.27; Pco,, 4.71 kPa; PO,, 32.8 kPa; Std bicarb, 16.9; Base excess, 9.1).

A careful, complete clinical examination was repeated, the patient now being fully awake. Although the abdomen was found to be completely pain free, soft and undistended, a diagnostic peritoneal lavage was performed. On insertion of the catheter there was an immediate backflow of stomach content, acid to litmus paper, suggesting rupture of the stomach. At lapatotomy there was a 15 cm laceration of the greater curvature of the stomach extending into the greater omentum. A small laceration on the inferior surface of the left lobe of the liver required no treatment. No other intra-abdominal injuries were found and after repair of the stomach and irrigation of the abdominal cavity the abdomen was closed. The patient made an uneventful postopera- tive recovery.

Case 2 A 31.year-old man was involved in a motor vehicle accident as a passenger on his way home from a party at which he had consumed large amounts of food and drink. He was taken to a provincial hospital accident department where he was found to be hypotensive (BP 90160mmHg) with a clinically obvious acute painful abdomen. The initial chest radiograph (Figure I) showed a fluid level in the pericardial sac consistent with traumatic haemo-

66 Injury: the British Journal of Accident Surgery (1993) Vol. 24/No. 1

commonest sites are anterior wall and greater curvature. Thoracic and diaphragmatic trauma and also other intra- abdominal organ injuries are commonly associated with gastric rupture (Brunsting and Morton, ,198~). Gastric rupture is usually easy to diagnose with an ‘acute abdomen’ and free intraperitoneal air as in our second case; the peritoneal lavage fluid return may be abnormally dark from action of the acid on the haemoglobin. It is important to diagnose the condition early since peritoneal soiling is usually extensive. Even with appropriate operation morbid- ity and mortality rates are high (Yajko et al., 1975; Brunsting and Morton, 1987), mostly from intra-abdominal sepsis which may require multiple reoperations.

Our first case had a clinically ‘benign’ abdomen, probably because pain from other injured areas distracted the patient from his abdominal condition. The alertness of the attending medical office in noticing the inappropriate metabolic acidosis saved the patient from a missed diagnosis and delay in laparotomy. In a properly resuscitated patient with inappropriately persisting metabolic acidosis and possible distracting injuries after blunt trauma, it may therefore be worthwhile to do peritoneal lavage to exclude a possible ruptured stomach. Another possibility which would have to be considered is rupture of the bladder, with resorption of hydrogen ions from the peritoneal cavity. This did not seem likely in our patient since there was no haematuria.

Figure 1. Patient 2: Chest radiograph shows intrapericardial fluid level.

pneumopericardium. A diagnostic peritoneal lavage was positive (obviously bloody) and he was taken to theatre for immediate laparotomy. A 1Ocm laceration of the greater curve of the stomach was repaired, as well as a 5 cm rupture of the central tendon of the diaphragm extending into the pericardial sac. There was extensive soiling with gastric contents and the pericardial and

peritoneal cavities were thoroughly washed out with large volumes of saline. Small capsular tears of liver and spleen required no intervention. The abdomen was closed without drainage. The patient had a stormy postoperative course with pulmonary oedema, pleural effusion and pericardial sepsis requiring thora- cotomy for drainage at a referral hospital. The patient required subsequent intensive care for 10 days.

Discussion

The stomach is normally resistant to rupture by blunt injury by virtue of.its excellent blood supply and tough wall. If the stomach is very distended after a large meal, for example, it may rupture more easily after relatively minor trauma (Yajko et al., 197.5). The most frequently reported causes are motor vehicle accidents and external cardiac compression, and the

The concurrent rupture of the stomach and the central diaphragm into the pericardial sac as seen in our second patient has not been reported to our knowledge. The diagnosis was relatively easy to make at the initial laparotomy. The operation was not delayed, but the complications were nevertheless severe. In retrospect, it may have been wiser to leave a drain in the pericardium postoperatively. The importance of thorough, adequate peritoneal lavage and toilet in gastric rupture cannot be overemphasized.

References

Brunsting L. A. and Morton J. H. (1987) Gastric rupture from blunt abdominal trauma. 1. Truuma 2 7, 887.

Yajko R. D., Seydel F. and Trimble C: (1975) Rupture of the stomach from blunt abdominal trauma. J. Trauma 15, 177.

Paper accepted 7 April 1992.

Repesfsfor reprints should be addressed to: J. D. Knottenbelt, Trauma Unit, Groote Schuur Hospital, Observatory 7925, South Africa.

Injury Research Group Annual Meeting Kabi Pharmacia, Milton Keynes, UK 5 April 1993 The Injury Research Group’s annual meeting will be held on Monday 5th April 1993 at Kabi Pharmacia, Milton Keynes. The morning session will be devoted to free communications and the afternoon to a symposium on Growth hormone, insulin-like growth factors and their relevance to trauma

Anyone wishing to receive further details, submit abstracts (deadline 1 lth January 1993) or join the mailing list for future meetings should contact Dr R N Barton, North Western Injury Research Centre, Stopford Building, Manchester University, Oxford Road, Manchester, Ml3 9pT, UK.