|Year : 2015 | Volume
| Issue : 1 | Page : 30-33
A rare form of domestic accidents: Penetrating abdominal injuries with evisceration of abdominal viscus
Nurudeen Toyin Abdulraheem1, Roland I Osuoji2, Oluwaseun R Akanbi1, Lukman Olajide Abdur-Rahman1, Abdulrasheed Adegoke Nasir1
1 Department of Surgery, Division of Paediatric Surgery, University of Ilorin Teaching Hospital, PMB 1459, Ilorin, Kwara State, Nigeria
2 Department of Surgery, Division of Paediatric Surgery, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
|Date of Web Publication||19-Nov-2015|
Dr. Nurudeen Toyin Abdulraheem
Department of Surgery, Division of Paediatric Surgery, University of Ilorin Teaching Hospital, PMB 1459, Ilorin, Kwara State
Source of Support: None, Conflict of Interest: None
Penetrating abdominal injury resulting from home accidents is rare. Only one such case was found in the English literature after online searching on PubMed. We report two cases of penetrating abdominal injury. The first was a 2-year-old girl who was brought into the emergency room (ER) with evisceration of most of the stomach through the left hypochondrium. She had fallen on a broken soft drink bottle; she was holding, after missing her steps. On examination, she had a penetrating injury in the left hypochondrium and a 1.5 cm perforation on the proximal aspect of the anterior wall of the stomach. She was explored within 3 h of presentation, during which the gastric perforation was closed eviscerated bowel returned into the peritoneum and primary wound closure achieved. The patient did well postoperatively. The second was a 9-month-old boy who was brought to the ER by parents on account of gut evisceration following injury from a soft drink bottle at home. He sustained injury from exploded soft drink bottle while crawling. Examination revealed a penetrating injury in the left upper quadrant with evisceration of small intestinal loops. He also had exploratory laparotomy within 4 h of presentation, during which intact abdominal viscera was found. Bowel loops were returned and primary abdominal closure done. Postoperatively, the patient did well. These cases are eye openers to an unusual form of domestic injury, exemplifying the potential hazards of soft drink bottles in the home. Awareness about this is pertinent.
Keywords: Broken soft drink bottle, evisceration of abdominal viscus, penetrating abdominal injury
|How to cite this article:|
Abdulraheem NT, Osuoji RI, Akanbi OR, Abdur-Rahman LO, Nasir AA. A rare form of domestic accidents: Penetrating abdominal injuries with evisceration of abdominal viscus. Afr J Trauma 2015;4:30-3
|How to cite this URL:|
Abdulraheem NT, Osuoji RI, Akanbi OR, Abdur-Rahman LO, Nasir AA. A rare form of domestic accidents: Penetrating abdominal injuries with evisceration of abdominal viscus. Afr J Trauma [serial online] 2015 [cited 2020 Oct 25];4:30-3. Available from: https://www.afrjtrauma.com/text.asp?2015/4/1/30/169817
| Introduction|| |
Domestic accidents are unintentional injuries that happen in or around the home., It is a general knowledge that there has been a role reversal between infectious diseases and accidents as causes of death since the end of Second World War, especially in the high-income countries., Most of these injuries are preventable. Hence, the term unintentional injury is gradually enjoying acceptance as a replacement for the accident. About 5 million deaths occur each year, from injuries and 80% of these are unintentional, accounting for almost a million childhood mortality annually., 95% of these deaths occur in the low and medium income countries (LMICs) to which West Africa sub-region belongs. More than half of childhood deaths result from unintentional injuries in children worldwide.,, The most common domestic injuries are falls, burns, drowning, poisoning, choking, and suffocation.,, The gastrointestinal injury may result from different mechanisms of injury, however, relatively low attention has been given to gastrointestinal trauma in the pediatric literature. Children more often have blunt abdominal injury as against penetrating abdominal injuries which are more common in adults. Even more uncommon is viscus evisceration resulting from childhood gastrointestinal injuries, as only one such case was recorded in an analytical study. The cases we are reporting a domestic unintentional penetrating abdominal injury which caused evisceration. This is quite an uncommon event from an, even more, uncommon object, hence the need to communicate this to the scientific community.
| Case Reports|| |
SK, a 2-year-old female kindergarten pupil presented to the emergency room (ER) with evisceration of abdominal viscus of 1 h duration. She was drinking from a bottle of soft drink when she tripped and fell with the bottle landing on the floor. She sustained abdominal injury with viscus evisceration. Her last meal was few minutes prior to the injury. There was minimal bleeding, and grains of rice were also seen to exit from the cut.
There was no vomiting, no hematemesis, and no abdominal distension; no fainting or loss of consciousness, no injury to any other part of the body.
She was calm, pale, and not febrile. Her vital signs were normal for her age. There was protrusion of part of the free end of the stomach from the left hypochondrium. There was no tenderness; a diagnosis of traumatic gastric evisceration was made.
She was resuscitated with 4.3% dextrose in 0.18% saline and a nasogastric tube was passed for gastric drainage. She had the viscus wrapped in saline soaked gauze and was commenced on intravenous prophylactic antibiotics.
She had exploratory laparotomy within 3 h of admission through a transverse supra-umbilical incision in the left hypochondrium that was extended to join the 4 cm laceration in the left hypochondrium. Intraoperative findings were an eviscerated stomach with contents exiting from a 1.5 cm single perforation on the anterior wall of the stomach [Figure 1]. The gastric perforation was repaired and returned into the peritoneum followed by warm saline lavage of the peritoneal cavity. Wound was then closed in layers with primary closure of the skin.
|Figure 1: Eviscerated stomach and ingested feed exiting through the perforation site|
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Immediate postoperative condition was satisfactory, however, attempt at commencing oral intake at 3rd day postoperative failed as she was vomiting. Full oral intake could only be established at 6th day postoperative. She developed superficial surgical site infection on the 4th day postoperative which improved with regular dressings. She was discharged 11 days after surgery to continue alternate day dressing as out-patient.
She was last seen in the clinic 1-week following discharge with no untoward complication.
OW, a 9-month-old male infant brought by parents on account of abdominal viscus evisceration of 90 min duration. He had crawled toward a filled, corked, soft drink bottle by his mother's side, while the mother was busy cooking. As the boy reached out for the bottle, it fell and broke with an explosive sound. Mother quickly lifted the boy off the ground only to find bowel loops dangling from the abdomen. No bleeding or luminal content seen no injury to other parts of the body. He was immediately taken to a nearby secondary health facility where the eviscerated viscus was wrapped in saline soaked gauze and subsequent referral to us. No illness prior to injury.
On examination, he was calm, not pale, and afebrile. Pulse – 140/min, regular, good volume. Respiratory rate was 40/min and temperature was 37.2°C. Chest was clinically clear. Abdomen was neatly dressed with crepe bandage, when opened revealed pink bowel loops lying on the abdominal wall. Digital rectal examination was normal. He was resuscitated with intravenous fluid. He had laparotomy within 4 h of presentation. Findings at surgery were small bowel loops on anterior abdominal wall [Figure 2] exiting through a 3 cm longitudinal laceration in the left upper quadrant, normal bowel loops, and other abdominal contents. Access was through a longitudinal incision proximal to, and joined to the laceration. The peritoneum was lavaged, contents returned and wound was closed in layers with primary closure of the skin. Postoperative period was uneventful, commenced oral intake 2nd postoperative day (POD) and discharge home 3rd POD. Wound had healed completely when seen at follow-up clinic at 9th POD [Figure 3].
|Figure 3: Healed scar in intestinal evisceration – 9th postoperative day|
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| Discussions|| |
While there is a decline in occurrence of infectious diseases worldwide, accidental deaths, and injuries are on the rise., This is a particular problem in the LMICs in which the rate of decline of infectious disease is not so rapid, yet > 95% of childhood unintentional injuries occur in these countries  leading to a double jeopardy. This is exemplified in the case 1 presented above in which surgical site infection was an additional morbidity. Reasons adduced to the highest burden of childhood injuries in the LMICs include lack of safe play spaces and global economic trend leading to rural – urban slums, child labor, among others. The 2 cases we are reporting occurred in the urban centers even though the parents were low income earners.
The majority of childhood injuries occur at home,,,, and those injured at home are found to be younger than those injured elsewhere, because they tend to spend more time in the home than outside. This is consistent with the index cases.
Predisposing factors to childhood unintentional injuries include lack of active supervision, crowded households, and cultural norms. Others are housing conditions and leaving in a deprived environment. Therefore, prevention can be achieved by keeping the environment safe and providing supervision , and communicating this to the community may be by in-home tutorials or provision of educational pamphlets. The former has been found to be more effective than the latter. Even though, largely preventable, childhood injury prevention is lagging behind other public health interventions, therefore, it is an area to be given attention.
The most common cause of childhood unintentional domestic injury is fall.,,, Other causes include burns, poisoning, drowning, sibling abuse motor vehicular injuries, and so on, with varying frequencies in different studies., Penetrating trauma of the gastrointestinal tract is less common in children compared to adults, probably because penetrating abdominal injuries are predominantly from interpersonal violence. Small intestine is the most frequently injured viscus in penetrating abdominal injury., Incidence of injury to the stomach is 0.9–1.8% because of its mobility and relative protection by the rib cage. However, these protections are obviated after a large meal which renders the stomach less mobile and partly exposed by descent from underneath the rib cage. Case 1 above is a typical illustration of this.
Penetrating abdominal wounds are frequent reasons for admission into ERs  and delays in presentation range from < 1 h to upward of 16 h., Both index cases presented in < 2 h. Mean in-hospital delay is found to be 3.4 ± 5.7 h in a study  and this is due mostly to high patient volume and competition for theatre space by different units. It is a general agreement that patients with hemodynamic instability or evisceration should undergo surgery without further investigation. Therefore, the evolving technique of diagnostic laparoscopy for trauma, with sensitivity and specificity of 90% and 100% respectively, high safety margin, and proven reduction of morbidity of negative laparotomy in abdominal trauma, should be used selectively., The index cases only had routine blood tests prior to surgery.
Rate of organ injuries in patients with evisceration is as high as 70–80%, hence the need for immediate laparotomy. Nontherapeutic laparotomies are encountered more after omental evisceration than after organ evisceration, and majority of the patients undergoing therapeutic laparotomy were found to have bowel perforation. Both index cases have organ evisceration, however, only one had viscus perforation, thence, therapeutic laparotomy.
The most influential predictors of outcome are the mechanism and severity of injury, as well as marked physiologic derangements. However, delays before surgery does not significantly affect outcome. Both index cases had no physiologic derangements at time of presentation and were operated within 2–3 h of hospital admission, mainly due to delays in securing theater spaces. The morbidity of prolonged hospital stay in case 1 was due to gastroparesis (causing delay in establishing full oral diet) and surgical site infection. The gastroparesis may be explained by the fact that the eviscerating viscus was a full stomach. The duration of its exposure to the atmosphere is also a likely culprit. Whereas, case 2 presented to us 90 min after injury, he had had afirst aid treatment (eviscerated bowel loops wrapped neatly with clean, saline-soaked gauze) at a nearby hospital within 30 min of injury, thereby limiting the duration of its exposure to the atmosphere. Furthermore, the eviscerating viscus was the small intestine and there was no injury to it.
| Conclusion|| |
The home environment should be made safe for children, who also need to be attended to in order to bring to the barest minimum, the incidence of unintentional injuries in the home. There should be legislations and educations to reduce and eventually phase out the use of breakable bottles for soft drinks.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]