Blunt intestinal injury in children: the role of the physical examination.

PURPOSE: Although blunt intestinal injury in children is uncommon, prompt recognition and treatment is imperative. Because the best method for diagnosis remains undetermined, the authors reviewed their experience with this injury in children to determine the most reliable diagnostic method and to identify factors associated with treatment delays.

METHODS

From January 1989 through December 1995, 2,284 children were admitted to the level I trauma center after sustaining blunt abdominal trauma. Of these, 32 (1.4%) had intestinal injury confirmed during laparotomy. Each case was reviewed with particular attention to the initial physical examination, abdominal computed tomography (CT) scan, laparotomy observations, complications, and the hospital at which the child was initially treated, if applicable. Fisher's Exact test and Wilcoxon's rank sum test were used for statistical analyses, with P < .05 considered significant.

RESULTS

Twenty-five patients (78%) had major intestinal injuries that required repair or resection; seven had minor intestinal injuries only. Two-thirds of the 32 were restrained passengers in motor vehicle crashes. The initial physical examination was suggestive of intestinal injury in 94% of children. Twenty-one children (84%) with major bowel injuries had diffuse abdominal tenderness at the time of initial physical examination, and only one of the seven (14%) with minor intestinal injury had generalized tenderness (P = .0014). Sixteen of 21 restrained passengers had seat-belt ecchymoses, and 13 of the 16 sustained major intestinal injuries. Only 1 of 13 abdominal CT scans performed was diagnostic of intestinal injury. Ten of 12 patients (83%) who underwent delayed laparotomy (more than 12 hours after injury) were initially evaluated at hospitals without trauma center designation; whereas 6 of the 20 nondelayed patients were evaluated at these hospitals (P = .0091). All four major complications occurred in the delayed group.

CONCLUSION

The authors conclude that signs suggestive of major intestinal injury are present in children at the time of initial physical examination or shortly thereafter. The decision to operate can be based on this examination alone in the pediatric population. Abdominal CT scan is not reliable for the diagnosis of blunt intestinal injury in children. To expedite diagnosis and treatment, children who sustain blunt abdominal trauma should be examined immediately by a physician experienced in pediatric trauma care or be transferred to a designated trauma center where this service is available.