Dept. of Pediatric Surgery AN UNUSUAL CASE OF POLYTRAUMA WITH PERFORATION PERITONITIS WITH KOCH’S ABDOMEN – A CHALLENGING MANAGEMENT. Dr. Badamutlang Dympep Dr. Shilpa Sharma Dr. Rohan Nautiyal Dr. Amita Sen Dept. of Pediatric Surgery PGIMER, Dr. RML Hospital New Delhi.

INTRODUCTION Blunt abdominal trauma (BAT) - serious cause of morbidity and mortality among pediatric age group. Intestinal disruptions can be due to a variety of types of blunt trauma (1) Delays in diagnosis of bowel injury are associated with complicated clinical courses and increased mortality (2) Associated Koch’s abdomen with BAT is rare.

CASE : HISTORY AND EXAMINATION A 7 year old boy , 1 day history of RTA with head injury and abdominal distension. GCS (7/15). H/R = 160/min . B/P = 60/40 mm OF Hg P/A - Distension with rigidity, absent bowel sounds.

INVESTIGATIONS BLOOD INV. : Hb = 11.2 gm % , PCV = 40.2 TLC = 16,600 /cu mm DLC = P75, L23, E1, M1. P/C = 2 lac / cu mm T. Protein = 5 gm / dl Albumin = 3.2 gm / dl SE = 138 / 4 KFT = 50 / 1.1

RADIOLOGICAL STUDIES : X-RAYS CHEST & ABDOMEN : Normal. USG ABDOMEN : Significant free fluid, no solid organ injury. NCCT HEAD : Depressed # Frontal bone with R. parietal comminuted fracture with underlying contusion with few air pockets.

NCCT HEAD:

MANAGEMENT Resuscitation and exploratory laparotomy. Findings : single old diseased perforation of 2 ˟ 2 cm in the distal jejunum. Multiple mesenteric LNs, ileocaecal wall thickening , tubercles studding the bowel and peritoneum . a distal loop jejunostomy was made with biopsy of LN and ulcer edge were sent.

INTRAOPERATIVE FINDINGS: Multiple tubercles studding the bowel wall. Enlarged mesenteric Lymph nodes.

HPE Report of 1st surgery : mesenteric lymph nodes : reactive lymphoid hyperplasia Ulcer margin : fibrino-suppurative exudate with lymphoid follicle and germinal centers. Vegetative material with foreign body giant cells.

Ulcer and perforation covered with fibrinosuppurative exudate and vegetative material

Vegetative material with foreign body giant cells

INVESTIGATIONS POST SURGERY: ESR = 26 mIu / ml. ELISA : negative. HIV I&II : negative. Mantoux test : Negative. Chest Xray = WNL. Sputum for AFB = Negative. CSF (LP): Proteins = 25 mg (15-45) Sugar = 60 mg (50-75) M/E = 40 cells / cu mm (TB meningitis) Predominantly lymphocytes. AFB = Negative.

COURSE IN POST-OPERATIVE PERIOD Anti- TB treatment started empirically based on intra-operative findings. Tuberculous meningitis 2 weeks post surgery based on clinical and LP. TPN was not advocated in view of sepsis. High output fistula : 50% weight loss in 3 weeks

COURSE IN POST-OPERATIVE PERIOD 4 weeks post surgery , jejunostomy closure was done. Patient recovered without any complications and discharged on ATT.

FOLLOW UP: The patient gained 30% of weight after 4 weeks of surgery and with anti- TB treatment.

DISCUSSION Small bowel perforation in BAT is difficult to diagnose. The coexistence of tuberculosis in a trauma patient is a challenging management. Small bowel perforation in BAT is difficult to diagnose.  A more aggressive approach with diagnostic and operative intervention reduce the mortality and morbidity.(3)

TAKE HOME MESSAGE NEVER RULE OUT CHRONIC DISEASES EVEN IF PT. COMES IN ACUTE SETTING. CLINICAL JUDGMENT IS SUPERIOR TO DIAGNOSTIC TESTS IN THE MANAGEMENT OF PEDIATRIC SMALL BOWEL INJURY. EARLY CLOSURE OF JEJUNOSTOMY WITH A GOOD ATT COVER IS POSSIBLE

REFERENCES:  Mukhopadhyay M. Intestinal Injury from Blunt Abdominal Trauma: A Study of47 Cases. Om Med J 2009; 24: 256-259 . Brownstein MR, Bunting T, Meyer AA, et al: Diagnosis and management of blunt small bowel injury: a survey of the membership of the American Association for the Surgery of Trauma. J Trauma2000; 48:402-407. Moss RL, Musemeche CA: Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg 31:1178- 1181; discussion 1181-1172, 1996.

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