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Perinephric fluid collection: An unusual presentation of bowel perforation
Injury Extra (2007) 38, 427—429
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CASE REPORT
Perinephric fluid collection: An unusual presentation of bowel perforation Muhammad Waseem *, Gerard Devas Department of Emergency Medicine, Lincoln Medical & Mental Health Center, 234 East 149th Street, Bronx, NY 10451, United States Accepted 11 February 2007
Case A 16-month-old previously healthy boy was brought to emergency department due to fever for 4 days and abdominal distension for 2 days. Her mother also reported history of excessive crying. He had vomited twice before presentation to the emergency department which was non-bilious. He had no diarrhoea or haematuria. On arrival in emergency department, he was pale and crying. His temperature was 38.7 8C, heart rate was 124 beats/min, and respiratory rate was 26 breaths/min. The chest was clear with bilateral air entry equal on both sides. His abdomen was soft but distended, and bowel sounds were hypoactive. He was also guarding during abdominal examination. His genital examination was normal. There were no abrasions, bruises or visible skin marks.His initial laboratory data included a complete blood count with a white blood cell count (WBC) of 17,800 mm 3, haemoglobin of 10.4 g/dL, haematocrit of 31.9% and platelet count of 620,000 mm 3. The WBC differential was 57% neutrophils, 25% lymphocytes and 6% monocytes. Serum sodium was 128 meq/L, potassium 4.2 meq/L, chloride 95 meq/L, bicarbonate 20 meq/L, blood urea nitro* Corresponding author. Tel.: +1 718 579 6010; fax: +1 718 579 4822. E-mail address: [email protected] (M. Waseem).
gen 13 mg/dL, creatinine 0.4 mg/dL, glucose 128 mg/dL and calcium 8.6 mg/dL. Amylase and lipase were 25 U/L (30—130) and 12 U/L, respectively. His lactate dehydrogenase level was 349 U/L (105—215) and liver function test was normal. Urinalysis showed small amount of blood. A plain abdominal radiograph showed distended bowel loops (Image 1). A contrast enhanced computed tomogram (CT) scan of abdomen revealed fluid around the left kidney, which dissected along the left psoas muscle and entered the peritoneal cavity (Image 2). On further questioning, parents recalled a fall from the chair in the last week, which they considered minor. He was taken to the operating room, and was found to have intestinal perforation. The child was also evaluated by child protection service and the injury was considered to be due to an accident.
Discussion Trauma may affect children of all ages. Children are usually more resilient than adults and gastrointestinal perforation due to blunt abdominal trauma is relatively uncommon. Although blunt trauma to the abdomen is more likely to injure solid organs, such as the liver, spleen, pancreas, and the kidneys, rupture of the bowel has been reported after blunt abdominal trauma.1,12,15,24,25
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.02.035
428
Image 1 Plain radiograph of abdomen showing dilated loops of bowel.
Hollow viscous perforation has been reported in up to 8% of children hospitalized after blunt abdominal trauma.7,8,10 Although any part of the bowel may be injured following blunt abdominal trauma, small intestinal injury is the most common site of perforation.4 Isolated intestinal perforation and perforation of colon after blunt abdominal trauma have also been reported. The exact location of bowel perforation differs with the mechanism of injury. The duodenum, jejunum and duodenojejunal junction are the common sites of perforation when associated with
M. Waseem, G. Devas non-accidental trauma.2 Most hollow viscous perforation occurs after major blunt abdominal trauma, but perforation has been reported even after minor abdominal trauma.3 Because these injuries are sometimes considered insignificant and parents may not recall a history of trauma on presentation to the emergency department. Diagnosis may therefore be delayed in the absence of a specific history of trauma, and non-specific symptoms. In some cases, bowel perforation has been discovered 7—10 days after the blunt abdominal trauma.5,13 A fluid collection in the perinephric space is always abnormal. The perinephric space is formed by anterior (Gerota’s) and posterior (Zuckerland’s) renal fascia. It is a cone shaped retroperitoneal space which contains the kidney, adrenal gland, perinephric fat, fibrous bridging septa and a rich network of perirenal vessel and lymphatics.11 Perinephric fluid may occur due to many causes (Table 1). Perinephric fluid may be pus, urine, blood, lymph exudates or transudate fluid resulting from abnormalities that arise within the kidney or adjacent retroperitoneal structures. Perinephric space pathology may originate from within or outside the confines of perirenal fascia. The two most common causes are perinephric abscess and haematoma. Perinephric haematoma may also arise from diseases originating outside the perinephric space. Bowel perforation has been reported as a rare cause of perinephric collection.17 Extra pancreatic fluid collection is also a well-recognized complication of pancreatitis and it may occur in unusual locations.6 A frequent site for extra pancreatic exudates is the pararenal space.9,16,21,23 Table 1
Causes of perinephric fluid collections
Perinephric abscess Primary Secondary (e.g., pancreatitis) Perinephric haematoma Traumatic Spontaneous Renal artery aneurysm Haematological disorders Vascular renal tumours Renal cell carcinoma Renal angiomyolipoma
Image 2 A contrast enhanced computed tomogram (CT) scan of abdomen showing fluid collection around the left kidney.
Conditions simulating perinephric fluid Perirenal non-Hodgkin’s lymphoma Acute cortical necrosis (circumferential hypo echoic rim) Retroperitoneal fibrosis Perirenal fat (perirenal halo)
Perinephric fluid collection: An unusual presentation of bowel perforation The initial presentation of children with blunt abdominal trauma may be non-specific or these patients may be asymptomatic. The common presentation is abdominal pain, tenderness and hypoactive bowel sounds.20 As the length of time from the initial traumatic event increases, signs of peritoneal irritation including fever, tachycardia and abdominal tenderness become evident. The physical findings may therefore become obvious only with serial abdominal examinations. The initial plain abdominal radiograph may not reveal findings of intestinal perforation. Ultrasound is an important imaging modality in the evaluation of patients with trauma.18 The perinephric fluid collection may appear as a decrease in the usual perinephric echogenicity. Ultrasound is able to detect free fluid in the abdomen and pelvis but it cannot differentiate between extravasated urine, blood, and other types of fluid, an often clinically important distinction, and cannot determine the source of bleeding.22 In addition, ultrasound is not very sensitive for retroperitoneal blood and hollow organ injury.14 CTscan is the most comprehensive diagnostic tool available for the evaluation of the victim of blunt abdominal trauma. It is useful in detecting both solid and hollow visceral injuries but intestinal injuries may be missed by CT scan.19
Conclusion Bowel perforation due to blunt abdominal trauma is rare in children. Diagnosis is frequently delayed because of inadequate or no history of trauma, non-specific symptoms or delayed physical findings. The diagnosis of bowel perforation is difficult in children, even with the use of plain radiography as well at CT imaging. The presence of perinephric fluid on CT should raise the suspicion of associated abdominal injury, such as bowel perforation. A high index of suspicion is essential for early diagnosis.
References 1. Barden BE, Maull KI. Perforation of the colon after blunt trauma. South Med J 2000;93(1):33—5. 2. Beckmann KR, Nozicka CA. Small bowel perforation: an unusual presentation for child abuse. J Am Osteopath Assoc 2000;100(8):496—7. 3. Bloom AI, Reissman P, Eid A, Durst AL. Isolated ileal perforation after minor blunt abdominal injury. Eur J Surg Acta Chir 1995;161(1):57—8.
429
4. Bruny JL, Bensard DD. Hollow viscous injury in the paediatric patient. Semin Pediatr Surg 2004;13(2):112—8. 5. Bubenik O, Meakins JL, McLean AP. Delayed perforation of the colon in blunt abdominal trauma. Can J Surg J Can Chir 1980;23(5):473—5. 6. Casolo F, Bianco R, Franceschelli N. Perirenal fluid collection complicating chronic pancreatitis: CT demonstration. Gastrointest Radiol 1987;12(2):117—20. 7. Cobb LM, Vinocur CD, Wagner CW, Weintraub WH. Intestinal perforation due to blunt trauma in children in an era of increased non-operative treatment. J Trauma 1986; 26(5):461—3. 8. Ford EG, Senac Jr MO. Clinical presentation and radiographic identification of small bowel rupture following blunt trauma in children. Pediatr Emerg Care 1993;9(3):139—42. 9. Griffin JF, Sekiya T, Isherwood I. Computed tomography of pararenal fluid collections in acute pancreatitis. Clin Radiol 1984;35(3):181—4. 10. Grosfeld JL, Rescorla FJ, West KW, Vane DW. Gastrointestinal injuries in childhood: analysis of 53 patients. J Pediatr Surg 1989;24(6):580—3. 11. Haddad MC, Hawary MM, Khoury NJ, Abi-Fakher FS, Ammouri NF, Al-Kutoubi AO. Radiology of perinephric fluid collections. Clin Radiol 2002;57(5):339—46. 12. Johnson D, Hamer DB. Perforation of the transverse colon as a result of minor blunt abdominal trauma. Injury 1997; 28(5—6):421—3. 13. Maull KI, Rozycki GS. Delayed presentation of traumatic blunt small bowel perforation. J Tenn Med Assoc 1986;79(5): 287—8. 14. Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so FAST. J Trauma 2003;54(1):52—9 [discussion 59—60]. 15. Mirvis SE, Gens DR, Shanmuganathan K. Rupture of the bowel after blunt abdominal trauma: diagnosis with CT. AJR Am J Roentgenol 1992;159(6):1217—21. 16. Mortele KJ, Mergo PJ, Taylor HM, Ernst MD, Ros PR. Renal and perirenal space involvement in acute pancreatitis: spiral CT findings. Abdom Imaging 2000;25(3):272—8. 17. Murray NW, Molavi A. Perinephric abscess: an unusual presentation of perforation of the colon. Johns Hopkins Med J 1977;140(1):15—8. 18. Noble VE, Brown DF. Renal ultrasound. Emerg Med Clin North Am 2004;22(3):641—59. 19. Sarihan H, Abes M. Non-operative management of intraabdominal bleeding due to blunt trauma in children: the risk of missed associated intestinal injuries. Pediatr Surg Int 1998;13(2—3):108—11. 20. Schenk 3rd WG, Lonchyna V, Moylan JA. Perforation of the jejunum from blunt abdominal trauma. J Trauma 1983;23(1): 54—6. 21. Siegelman SS, Copeland BE, Saba GP, Cameron JL, Sanders RC, Zerhouni EA. CT of fluid collections associated with pancreatitis. AJR Am J Roentgenol 1980;134(6):1121—32. 22. Smith JK, Kenney PJ. Imaging of renal trauma. Radiol Clin North Am 2003;41(5):1019—35. 23. Susman N, Hammerman AM, Cohen E. The renal halo sign in pancreatitis. Radiology 1982;142(2):323—7. 24. Vertruyen M, Nardini J, Bruyns J. Isolated perforations of the small bowel from blunt abdominal trauma. Report of two cases and review of the literature. Acta Chir Belg 1995;95(2):76—80. 25. Zafar A, Orakzai N, Ghafoor A, Ahmad S. Gastrointestinal perforation in children due to blunt abdominal trauma in Hazara, Northern Pakistan. Trop Doct 2003;33(3):168—70.
www.elsevier.com/locate/inext
CASE REPORT
Perinephric fluid collection: An unusual presentation of bowel perforation Muhammad Waseem *, Gerard Devas Department of Emergency Medicine, Lincoln Medical & Mental Health Center, 234 East 149th Street, Bronx, NY 10451, United States Accepted 11 February 2007
Case A 16-month-old previously healthy boy was brought to emergency department due to fever for 4 days and abdominal distension for 2 days. Her mother also reported history of excessive crying. He had vomited twice before presentation to the emergency department which was non-bilious. He had no diarrhoea or haematuria. On arrival in emergency department, he was pale and crying. His temperature was 38.7 8C, heart rate was 124 beats/min, and respiratory rate was 26 breaths/min. The chest was clear with bilateral air entry equal on both sides. His abdomen was soft but distended, and bowel sounds were hypoactive. He was also guarding during abdominal examination. His genital examination was normal. There were no abrasions, bruises or visible skin marks.His initial laboratory data included a complete blood count with a white blood cell count (WBC) of 17,800 mm 3, haemoglobin of 10.4 g/dL, haematocrit of 31.9% and platelet count of 620,000 mm 3. The WBC differential was 57% neutrophils, 25% lymphocytes and 6% monocytes. Serum sodium was 128 meq/L, potassium 4.2 meq/L, chloride 95 meq/L, bicarbonate 20 meq/L, blood urea nitro* Corresponding author. Tel.: +1 718 579 6010; fax: +1 718 579 4822. E-mail address: [email protected] (M. Waseem).
gen 13 mg/dL, creatinine 0.4 mg/dL, glucose 128 mg/dL and calcium 8.6 mg/dL. Amylase and lipase were 25 U/L (30—130) and 12 U/L, respectively. His lactate dehydrogenase level was 349 U/L (105—215) and liver function test was normal. Urinalysis showed small amount of blood. A plain abdominal radiograph showed distended bowel loops (Image 1). A contrast enhanced computed tomogram (CT) scan of abdomen revealed fluid around the left kidney, which dissected along the left psoas muscle and entered the peritoneal cavity (Image 2). On further questioning, parents recalled a fall from the chair in the last week, which they considered minor. He was taken to the operating room, and was found to have intestinal perforation. The child was also evaluated by child protection service and the injury was considered to be due to an accident.
Discussion Trauma may affect children of all ages. Children are usually more resilient than adults and gastrointestinal perforation due to blunt abdominal trauma is relatively uncommon. Although blunt trauma to the abdomen is more likely to injure solid organs, such as the liver, spleen, pancreas, and the kidneys, rupture of the bowel has been reported after blunt abdominal trauma.1,12,15,24,25
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.02.035
428
Image 1 Plain radiograph of abdomen showing dilated loops of bowel.
Hollow viscous perforation has been reported in up to 8% of children hospitalized after blunt abdominal trauma.7,8,10 Although any part of the bowel may be injured following blunt abdominal trauma, small intestinal injury is the most common site of perforation.4 Isolated intestinal perforation and perforation of colon after blunt abdominal trauma have also been reported. The exact location of bowel perforation differs with the mechanism of injury. The duodenum, jejunum and duodenojejunal junction are the common sites of perforation when associated with
M. Waseem, G. Devas non-accidental trauma.2 Most hollow viscous perforation occurs after major blunt abdominal trauma, but perforation has been reported even after minor abdominal trauma.3 Because these injuries are sometimes considered insignificant and parents may not recall a history of trauma on presentation to the emergency department. Diagnosis may therefore be delayed in the absence of a specific history of trauma, and non-specific symptoms. In some cases, bowel perforation has been discovered 7—10 days after the blunt abdominal trauma.5,13 A fluid collection in the perinephric space is always abnormal. The perinephric space is formed by anterior (Gerota’s) and posterior (Zuckerland’s) renal fascia. It is a cone shaped retroperitoneal space which contains the kidney, adrenal gland, perinephric fat, fibrous bridging septa and a rich network of perirenal vessel and lymphatics.11 Perinephric fluid may occur due to many causes (Table 1). Perinephric fluid may be pus, urine, blood, lymph exudates or transudate fluid resulting from abnormalities that arise within the kidney or adjacent retroperitoneal structures. Perinephric space pathology may originate from within or outside the confines of perirenal fascia. The two most common causes are perinephric abscess and haematoma. Perinephric haematoma may also arise from diseases originating outside the perinephric space. Bowel perforation has been reported as a rare cause of perinephric collection.17 Extra pancreatic fluid collection is also a well-recognized complication of pancreatitis and it may occur in unusual locations.6 A frequent site for extra pancreatic exudates is the pararenal space.9,16,21,23 Table 1
Causes of perinephric fluid collections
Perinephric abscess Primary Secondary (e.g., pancreatitis) Perinephric haematoma Traumatic Spontaneous Renal artery aneurysm Haematological disorders Vascular renal tumours Renal cell carcinoma Renal angiomyolipoma
Image 2 A contrast enhanced computed tomogram (CT) scan of abdomen showing fluid collection around the left kidney.
Conditions simulating perinephric fluid Perirenal non-Hodgkin’s lymphoma Acute cortical necrosis (circumferential hypo echoic rim) Retroperitoneal fibrosis Perirenal fat (perirenal halo)
Perinephric fluid collection: An unusual presentation of bowel perforation The initial presentation of children with blunt abdominal trauma may be non-specific or these patients may be asymptomatic. The common presentation is abdominal pain, tenderness and hypoactive bowel sounds.20 As the length of time from the initial traumatic event increases, signs of peritoneal irritation including fever, tachycardia and abdominal tenderness become evident. The physical findings may therefore become obvious only with serial abdominal examinations. The initial plain abdominal radiograph may not reveal findings of intestinal perforation. Ultrasound is an important imaging modality in the evaluation of patients with trauma.18 The perinephric fluid collection may appear as a decrease in the usual perinephric echogenicity. Ultrasound is able to detect free fluid in the abdomen and pelvis but it cannot differentiate between extravasated urine, blood, and other types of fluid, an often clinically important distinction, and cannot determine the source of bleeding.22 In addition, ultrasound is not very sensitive for retroperitoneal blood and hollow organ injury.14 CTscan is the most comprehensive diagnostic tool available for the evaluation of the victim of blunt abdominal trauma. It is useful in detecting both solid and hollow visceral injuries but intestinal injuries may be missed by CT scan.19
Conclusion Bowel perforation due to blunt abdominal trauma is rare in children. Diagnosis is frequently delayed because of inadequate or no history of trauma, non-specific symptoms or delayed physical findings. The diagnosis of bowel perforation is difficult in children, even with the use of plain radiography as well at CT imaging. The presence of perinephric fluid on CT should raise the suspicion of associated abdominal injury, such as bowel perforation. A high index of suspicion is essential for early diagnosis.
References 1. Barden BE, Maull KI. Perforation of the colon after blunt trauma. South Med J 2000;93(1):33—5. 2. Beckmann KR, Nozicka CA. Small bowel perforation: an unusual presentation for child abuse. J Am Osteopath Assoc 2000;100(8):496—7. 3. Bloom AI, Reissman P, Eid A, Durst AL. Isolated ileal perforation after minor blunt abdominal injury. Eur J Surg Acta Chir 1995;161(1):57—8.
429
4. Bruny JL, Bensard DD. Hollow viscous injury in the paediatric patient. Semin Pediatr Surg 2004;13(2):112—8. 5. Bubenik O, Meakins JL, McLean AP. Delayed perforation of the colon in blunt abdominal trauma. Can J Surg J Can Chir 1980;23(5):473—5. 6. Casolo F, Bianco R, Franceschelli N. Perirenal fluid collection complicating chronic pancreatitis: CT demonstration. Gastrointest Radiol 1987;12(2):117—20. 7. Cobb LM, Vinocur CD, Wagner CW, Weintraub WH. Intestinal perforation due to blunt trauma in children in an era of increased non-operative treatment. J Trauma 1986; 26(5):461—3. 8. Ford EG, Senac Jr MO. Clinical presentation and radiographic identification of small bowel rupture following blunt trauma in children. Pediatr Emerg Care 1993;9(3):139—42. 9. Griffin JF, Sekiya T, Isherwood I. Computed tomography of pararenal fluid collections in acute pancreatitis. Clin Radiol 1984;35(3):181—4. 10. Grosfeld JL, Rescorla FJ, West KW, Vane DW. Gastrointestinal injuries in childhood: analysis of 53 patients. J Pediatr Surg 1989;24(6):580—3. 11. Haddad MC, Hawary MM, Khoury NJ, Abi-Fakher FS, Ammouri NF, Al-Kutoubi AO. Radiology of perinephric fluid collections. Clin Radiol 2002;57(5):339—46. 12. Johnson D, Hamer DB. Perforation of the transverse colon as a result of minor blunt abdominal trauma. Injury 1997; 28(5—6):421—3. 13. Maull KI, Rozycki GS. Delayed presentation of traumatic blunt small bowel perforation. J Tenn Med Assoc 1986;79(5): 287—8. 14. Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so FAST. J Trauma 2003;54(1):52—9 [discussion 59—60]. 15. Mirvis SE, Gens DR, Shanmuganathan K. Rupture of the bowel after blunt abdominal trauma: diagnosis with CT. AJR Am J Roentgenol 1992;159(6):1217—21. 16. Mortele KJ, Mergo PJ, Taylor HM, Ernst MD, Ros PR. Renal and perirenal space involvement in acute pancreatitis: spiral CT findings. Abdom Imaging 2000;25(3):272—8. 17. Murray NW, Molavi A. Perinephric abscess: an unusual presentation of perforation of the colon. Johns Hopkins Med J 1977;140(1):15—8. 18. Noble VE, Brown DF. Renal ultrasound. Emerg Med Clin North Am 2004;22(3):641—59. 19. Sarihan H, Abes M. Non-operative management of intraabdominal bleeding due to blunt trauma in children: the risk of missed associated intestinal injuries. Pediatr Surg Int 1998;13(2—3):108—11. 20. Schenk 3rd WG, Lonchyna V, Moylan JA. Perforation of the jejunum from blunt abdominal trauma. J Trauma 1983;23(1): 54—6. 21. Siegelman SS, Copeland BE, Saba GP, Cameron JL, Sanders RC, Zerhouni EA. CT of fluid collections associated with pancreatitis. AJR Am J Roentgenol 1980;134(6):1121—32. 22. Smith JK, Kenney PJ. Imaging of renal trauma. Radiol Clin North Am 2003;41(5):1019—35. 23. Susman N, Hammerman AM, Cohen E. The renal halo sign in pancreatitis. Radiology 1982;142(2):323—7. 24. Vertruyen M, Nardini J, Bruyns J. Isolated perforations of the small bowel from blunt abdominal trauma. Report of two cases and review of the literature. Acta Chir Belg 1995;95(2):76—80. 25. Zafar A, Orakzai N, Ghafoor A, Ahmad S. Gastrointestinal perforation in children due to blunt abdominal trauma in Hazara, Northern Pakistan. Trop Doct 2003;33(3):168—70.