Presentation
Fall from bicycle. Body hit the handlebars. Abdominal pain. No distension.
Patient Data
XR at a peripheral hospital
Chest x-ray: supine
The lungs are clear.
No subdiaphragmatic gas.
Abdominal x-ray
No bowel obstruction. No free gas.
Large volume pneumoperitoneum.
Several small foci of gas, together with mesenteric fluid and stranding at the left upper abdomen. There is potential discontinuity of the colonic splenic flexure. Thickening of the jejunum.
Moderate free fluid in pelvis.
Two small splenic lacerations on the inferolateral aspect.
The remainder of the solid organs are normal.
Large perforation of the jejenum 40cm from the DJ flexure.
Case Discussion
The commonest site of traumatic small bowel perforation is the jejunum (near the ligament of Trietz / DJ flexure), as in this case. However, It is often the case that this cannot be identified on CT. In fact, the larger the pneumoperitoneum the harder it often is to localized the site of a perforation.
This is one of the classical mechanisms of injury for a jejunal perforation. Blunt abdominal injury from hitting the handle bars after a fall from a bicycle. It is more typically observed in children.
The intra-operative images show the site of the injury, although the site is difficult if not impossible to identify on the CT.
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