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Ischaemic colitis with perforation in a patient with multiple injuries
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Injury, 14,100-102
Printed in Great Britain
Ischaemic colitis with perforation in a patient with multiple injuries H. R. Guly and I. P. Stewart Accident and Emergency Department, Freedom Fields Hospital Plymouth Summary We report a case of ischaemic colitis with perforation of the hepatic flexure, in a 19-year-old man with multiple injuries. We discuss the aetiology of this and review the literature.
2. Fracture-disclocation of T? on T8 with paraplegia. 3. Right pneumothorax and bilateral pulmonary contusion. 4. injury ofthe right brachial plexus.
Management INTRODUCTION TRAUMATIC intestinal infarction is u n c o m m o n . Dubois et al. (I 979) reviewed the literature and found only 25 cases, though an additional case had been described by Rickert et al. (1974). O f these 26 cases, I I were due to venous thrombosis and 5 were caused by arterial occlusion; in 2, the larger vessels were patent and in the remainder, the state of the vessels was not reported. These were all diagnosed at laparotomy or autopsy. Less severe vascular damage may cause ischaemic colitis, diagnosable by barium enema, and a single case of post-traumatic ischaemic colitis has been reported ( H u m p h r e y s and G r a h a m , 1979). We wish to describe a patient with a posttraumatic ischaemic colitis with perforation, which was diagnosed by a barium enema.
CASE REPORT A 19-year-old student fell from a cliff, landing on the beach below, where he was found lying on his back. He arrived at hospital 4 hours after falling and on examination he was severely shocked with a systolic blood pressure of 60 mmH~,. His injuries were: I. Fractures of the right parietal bone and base of skull with a right facial palsy of the lower motor neurone type.
After resuscitation, peritoneal lavage was performed and the returned fluid was clear. His chest injury was severe enough to require ventilation until the fifth day. On the seventh day he was pyrexial and although his chest X-ray film was clear, a sputum culture grew pseudomonas and he was treated with gentamicin. The following day he developed a Gram-negative septicaemia with no obvious cause, and benzyl penicillin, metronidazole and methyl prednisolone were given, in addition to gentamicin. Blood cultures subsequently showed no growth. By the tenth day he was much better but developed a single melaena, for which cimetidine was given. By the eleventh day he began to drink and later he took food. He continued to be pyrexial and to have diarrhoea 6 to 8 times per day, and, on the eighteenth day, a barium enema (see Fig. I) showed ischaemic colitis of the ascending and transverse colon and a perforation of the hepatic flexure. He was treated conservatively with antibiotics and fluids and his overall condition gradually improved, until he was fit to be transferred to a spinal injuries unit 6 weeks after his fall. One year following his injury, he remains well and has had no further bowel symptoms. He has had no further barium investigations.
DISCUSSION Diagnosis T h e s y m p t o m s of ischaemic colitis are pain, diarrhoea and rectal bleeding. O u r patient was unable to feel a b d o m i n a l pain and although he had diarrhoea, there was no macroscopic rectal
Guly and Stewart: Ischaemic Colitis with Perforation
Fig. 1. Barium enema on the eighteenth day, showing
ischaemic colitis of the ascending and transverse colon, with perforation at the hepatic flexure. bleeding, other than the melaena on the tenth day. The diagnosis of ischaemic colitis, therefore, mainly rests on the radiological appearance of the ascending and transverse colon. The most common sites ofischaemic colitis are the splenic flexure, descending colon, or sigmoid colon, but it may occur anywhere in the colon and the site o f t h e colitis in this patient is the same as in the patient described by Rickert et al. (1974). The septicaemia which he developed was probably related to the perforation and there can be little doubt that had he not been paraplegic, he would have developed symptoms and signs before this and that ischaemic bowel would have been found at laparotomy. Mild ischaemic colitis may be completely reversible. However, in a patient with muscle involvement as evidenced by the perforation, one would expect late stricture formation, but as our patient is asymptomatic, he had no further barium studies.
Aetiology This patient had no obvious injury of the abdomen and a negative peritoneal lavage, but it
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is clearly impossible to exclude an abdominal injury to account, at least in part, for his ischaemic colitis. However, it seems more likely that his severe, prolonged hypotension was the major factor. Renton (1967) and Rickert et al. (1974) have both described bowel infarction in patients who were hypotensive as a result of injury, but with no abdominal injury. Both these patients had patent large vessels and the mechanism of infarction was thought to be small vessel thrombosis as a result of poor perfusion during the period of hypotension. The patient with ischaemic colitis described by Humphreys and G r a h a m (1979) had been hypotensive from a femoral artery laceration and had had no abdominal injury. Delayed perforation of the colon following blunt abdominal injury is uncommon but recognized (Wightman, 1967; Bolton et al., 1973), it is usually intraperitoneal, but retroperitoneal rupture and colocutaneous fistula have been described, lschaemia is not the only cause of this, as a crushing injury of the colon may lead to necrosis and perforation, or an intramural haematoma may rupture. However, the barium enema appearance in our case suggested ischaemia, rather than any such local cause.
Conclusion In any patient who has been shocked as a result of injury and who later develops abdominal symptoms or signs, bowel ischaemia or infarction should be considered, even ifthere has been no abdominal injury. Tibbs et al. (1980) have commented on the difficulty in diagnosing abdominal injuries in patients with spinal shock and recommended routine peritoneal lavage in such patients. As perforation of the colon may occur as a late event, a repeat peritoneal lavage might be helpful in the presence of new or continuing 'unexplained' signs. REFERENCES Bolton P. M., Wood C. B., Quartey-Papafio J. B. et al. (1973) Blunt abdominal injury: a review of 59 consecutive cases undergoing surgery. Br. J. Surg.
60,657. Dubois F., De La Vaissi6re G. and Pouliquen E. (1979) L'infarctus intestinal traumatique. J. Chit. (Paris) 116,343. Humphreys W. G. and Graham W. J. H. (1979) lschaemic colitis: a sequel to femoral artery laceration. Injut3' 10, 217. Renton C. J. C. (1967) Massive intestinal infarction following multiple injury. Br. J. Surg. 54,399.
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Rickert R. R., Johnson R. G. and Wignarajan K. R. (1974) Ischaemic colitis in a young adult patient: report of a case. Dis. Colon Rectum 17, I 12. Tibbs P. A., Young A. B., Bivins B. A. et al. (1980) Diagnosis of acute abdominal injuries in patients with spinal shock: value of diagnostic peritoneal lavage. J. Trauma 20, 55.
Injury: the British Journal of Accident Surgery Vol. 14/No. 1
Wightman J. A. K. (1967) Delayed traumatic rupture of colon with colo-cutaneous fistula. Br. Med. J. 2, 93.
Requests./br reprints should be addressed to: Dr H. R. Guly, Accident and Emergency Department, Royal Devon and Exeter Hospital, Exeter, Devon.
Injury, 14,100-102
Printed in Great Britain
Ischaemic colitis with perforation in a patient with multiple injuries H. R. Guly and I. P. Stewart Accident and Emergency Department, Freedom Fields Hospital Plymouth Summary We report a case of ischaemic colitis with perforation of the hepatic flexure, in a 19-year-old man with multiple injuries. We discuss the aetiology of this and review the literature.
2. Fracture-disclocation of T? on T8 with paraplegia. 3. Right pneumothorax and bilateral pulmonary contusion. 4. injury ofthe right brachial plexus.
Management INTRODUCTION TRAUMATIC intestinal infarction is u n c o m m o n . Dubois et al. (I 979) reviewed the literature and found only 25 cases, though an additional case had been described by Rickert et al. (1974). O f these 26 cases, I I were due to venous thrombosis and 5 were caused by arterial occlusion; in 2, the larger vessels were patent and in the remainder, the state of the vessels was not reported. These were all diagnosed at laparotomy or autopsy. Less severe vascular damage may cause ischaemic colitis, diagnosable by barium enema, and a single case of post-traumatic ischaemic colitis has been reported ( H u m p h r e y s and G r a h a m , 1979). We wish to describe a patient with a posttraumatic ischaemic colitis with perforation, which was diagnosed by a barium enema.
CASE REPORT A 19-year-old student fell from a cliff, landing on the beach below, where he was found lying on his back. He arrived at hospital 4 hours after falling and on examination he was severely shocked with a systolic blood pressure of 60 mmH~,. His injuries were: I. Fractures of the right parietal bone and base of skull with a right facial palsy of the lower motor neurone type.
After resuscitation, peritoneal lavage was performed and the returned fluid was clear. His chest injury was severe enough to require ventilation until the fifth day. On the seventh day he was pyrexial and although his chest X-ray film was clear, a sputum culture grew pseudomonas and he was treated with gentamicin. The following day he developed a Gram-negative septicaemia with no obvious cause, and benzyl penicillin, metronidazole and methyl prednisolone were given, in addition to gentamicin. Blood cultures subsequently showed no growth. By the tenth day he was much better but developed a single melaena, for which cimetidine was given. By the eleventh day he began to drink and later he took food. He continued to be pyrexial and to have diarrhoea 6 to 8 times per day, and, on the eighteenth day, a barium enema (see Fig. I) showed ischaemic colitis of the ascending and transverse colon and a perforation of the hepatic flexure. He was treated conservatively with antibiotics and fluids and his overall condition gradually improved, until he was fit to be transferred to a spinal injuries unit 6 weeks after his fall. One year following his injury, he remains well and has had no further bowel symptoms. He has had no further barium investigations.
DISCUSSION Diagnosis T h e s y m p t o m s of ischaemic colitis are pain, diarrhoea and rectal bleeding. O u r patient was unable to feel a b d o m i n a l pain and although he had diarrhoea, there was no macroscopic rectal
Guly and Stewart: Ischaemic Colitis with Perforation
Fig. 1. Barium enema on the eighteenth day, showing
ischaemic colitis of the ascending and transverse colon, with perforation at the hepatic flexure. bleeding, other than the melaena on the tenth day. The diagnosis of ischaemic colitis, therefore, mainly rests on the radiological appearance of the ascending and transverse colon. The most common sites ofischaemic colitis are the splenic flexure, descending colon, or sigmoid colon, but it may occur anywhere in the colon and the site o f t h e colitis in this patient is the same as in the patient described by Rickert et al. (1974). The septicaemia which he developed was probably related to the perforation and there can be little doubt that had he not been paraplegic, he would have developed symptoms and signs before this and that ischaemic bowel would have been found at laparotomy. Mild ischaemic colitis may be completely reversible. However, in a patient with muscle involvement as evidenced by the perforation, one would expect late stricture formation, but as our patient is asymptomatic, he had no further barium studies.
Aetiology This patient had no obvious injury of the abdomen and a negative peritoneal lavage, but it
101
is clearly impossible to exclude an abdominal injury to account, at least in part, for his ischaemic colitis. However, it seems more likely that his severe, prolonged hypotension was the major factor. Renton (1967) and Rickert et al. (1974) have both described bowel infarction in patients who were hypotensive as a result of injury, but with no abdominal injury. Both these patients had patent large vessels and the mechanism of infarction was thought to be small vessel thrombosis as a result of poor perfusion during the period of hypotension. The patient with ischaemic colitis described by Humphreys and G r a h a m (1979) had been hypotensive from a femoral artery laceration and had had no abdominal injury. Delayed perforation of the colon following blunt abdominal injury is uncommon but recognized (Wightman, 1967; Bolton et al., 1973), it is usually intraperitoneal, but retroperitoneal rupture and colocutaneous fistula have been described, lschaemia is not the only cause of this, as a crushing injury of the colon may lead to necrosis and perforation, or an intramural haematoma may rupture. However, the barium enema appearance in our case suggested ischaemia, rather than any such local cause.
Conclusion In any patient who has been shocked as a result of injury and who later develops abdominal symptoms or signs, bowel ischaemia or infarction should be considered, even ifthere has been no abdominal injury. Tibbs et al. (1980) have commented on the difficulty in diagnosing abdominal injuries in patients with spinal shock and recommended routine peritoneal lavage in such patients. As perforation of the colon may occur as a late event, a repeat peritoneal lavage might be helpful in the presence of new or continuing 'unexplained' signs. REFERENCES Bolton P. M., Wood C. B., Quartey-Papafio J. B. et al. (1973) Blunt abdominal injury: a review of 59 consecutive cases undergoing surgery. Br. J. Surg.
60,657. Dubois F., De La Vaissi6re G. and Pouliquen E. (1979) L'infarctus intestinal traumatique. J. Chit. (Paris) 116,343. Humphreys W. G. and Graham W. J. H. (1979) lschaemic colitis: a sequel to femoral artery laceration. Injut3' 10, 217. Renton C. J. C. (1967) Massive intestinal infarction following multiple injury. Br. J. Surg. 54,399.
102
Rickert R. R., Johnson R. G. and Wignarajan K. R. (1974) Ischaemic colitis in a young adult patient: report of a case. Dis. Colon Rectum 17, I 12. Tibbs P. A., Young A. B., Bivins B. A. et al. (1980) Diagnosis of acute abdominal injuries in patients with spinal shock: value of diagnostic peritoneal lavage. J. Trauma 20, 55.
Injury: the British Journal of Accident Surgery Vol. 14/No. 1
Wightman J. A. K. (1967) Delayed traumatic rupture of colon with colo-cutaneous fistula. Br. Med. J. 2, 93.
Requests./br reprints should be addressed to: Dr H. R. Guly, Accident and Emergency Department, Royal Devon and Exeter Hospital, Exeter, Devon.