Three-decade-delayed post-traumatic small-bowel stenosis

Jonas Paul DeMuro*Department of Surgery, Winthrop University Hospital, Mineola, New York, USA.

Injury to the small bowel is uncommon after trauma. There are rare reported cases of delayed post-traumaticstenosis of the small bowel occurring weeks, months or even years later. In this study, we present a case of adelayed stenosis that caused a small-bowel obstruction three decades after the trauma.

Introduction

The differential diagnosis of a small-bowel obstructionin a patient with no prior operation is expansive, andincludes common problems, such as a hernia, aningested foreign body, and a tumour. One quiteunusual diagnosis to include is a delayed small-boweltraumatic stenosis, of which we report a case. Unfor-tunately, even with modern imaging techniques, thediagnosis cannot be made on preoperative imaging,but rather at the time of the exploratory laparotomy.

Case report

A 52-year-old man presented to the emergencydepartment with a 2-day history of abdominal painassociated with nausea, vomiting and obstipation. Theexam was significant for moderate abdominal disten-sion and pain in the lower quadrants bilaterally, butthere were no peritoneal findings. He had no pastmedical history or past surgical history; however, hewas ‘run over’ by a powerboat 30 years prior, andhospitalized for 5 days for concern of a spleen injury.

While his admission vitals were normal, he did havean elevated lactate to 4 on initial presentation, and awhite blood cell count of 11.8. His chemistries dem-onstrated dehydration, with a blood urea nitrogen of22. His admission computed tomography (CT) wassignificant for a high-grade, partial small-bowelobstruction, with a transition zone in the right lowerquadrant (Fig. 1).

Emergent laparotomy revealed a proximal dis-tended bowel without perforation, no mesentericdefect or adhesions and a single area of small-bowelstenosis 20 cm from the terminal ileum. This was

resected, and bowel continuity was re-establishedwith a stapled side-to-side anastomosis. The patient’spostoperative course was uneventful, with no subse-quent symptoms.

Final pathology revealed a small bowel with erosion,marked oedema, focal fibrosis and acute inflammationconsistent with a stricture, without any evidence ofinflammatory bowel disease.

Discussion

Injury to the small bowel from blunt trauma is anuncommon event. Delayed small-bowel stenosis isquite rare, with a 1967 review article finding only 48cases since 1901,1 and an additional 12 casesreported from 1994.2 The proposed mechanism is notdirect trauma to the small bowel, but rather injury to themesenteric blood supply, which causes a haemor-rhagic infarction to the mucosa, while allowing theserosa to retain its integrity, resulting in a stenosis.3

There have been criteria proposed for the diagnosisof a post-traumatic small-bowel obstruction: (i) historyof blunt abdominal trauma; (ii) no apparent illnessbefore the trauma; (iii) development of intestinal symp-toms after the trauma; (iv) confirmed intestinal steno-sis; and (v) absence of inflammatory or neoplasticchanges in the stenotic segment of the resected smallbowel.4 The onset of symptoms is typically within thefirst 4–8 weeks of the initial injury; however, there havebeen cases reported up to 18 years after the trauma.3

Diagnosis can be difficult, and often delayed; small-bowel contrast studies and CT scans can be usefulto determine the level of obstruction, as well as toexclude other causes of bowel obstruction.5

Conclusion

Patients with a history of blunt abdominal trauma whodevelop a small-bowel obstruction, even decades

*Author to whom all correspondence should be addressed.Email: jdemuro@winthrop.orgReceived 21 December 2011; accepted 25 January 2013.

bs_bs_bannerSurgical Practicedoi:10.1111/1744-1633.12065 Case Report

© 2014 College of Surgeons of Hong Kong Surgical Practice (2014) 18, 191–192

later, should raise the concern for a diagnosis of post-traumatic small-bowel stricture. This case shows theuse of CT to demonstrate the obstruction, and repre-sents the longest delayed small-bowel stenosisreported to date.

Declaration of conflict of interest

All authors declare that they have no conflicts ofinterest.

References

1. Gillet M, Phillipe E, Adloft M. Les stenoses cicatricielles del’intestin grele après contusion de l’abdomen. J. Chir. (Paris)1967; 93: 469–77.

2. Allen JC. Posttraumatic small bowel obstruction. J. R. ArmyMed. Corps 1994; 140: 47–8.

3. Bryner UM, Longerbeam JK, Reeves CD. Posttraumaticischemic stenosis of the small bowel. Arch. Surg. 1980; 115:1039–41.

4. Konobu T, Murao Y, Miyamoto S et al. Posttraumatic intestinalstenosis presenting as a perforation: report of a case. Jpn J.Surg. 1999; 29: 564–7.

5. Lee-Elliot C, Landells W, Keane A. Using CT to reveal trau-matic ischemic stricture of the terminal ileum. AJR Am. J.Roentgenol. 2002; 178: 403–4.

Fig. 1. Computed tomography of the abdomen and pelvis(coronal view, intravenous and oral contrast) demonstrates thesmall-bowel obstruction. Arrow points to the area of stenosis.

JP DeMuro192

© 2014 College of Surgeons of Hong Kong Surgical Practice (2014) 18, 191–192