Blunt gastric rupture: a plural clinical presentation and literature review

Background

In a blunt trauma context, gastric rupture is an uncommon lesion. It happens because the stomach is anatomically protected by ribs and adjacent parenchymatous organs anatomically protect the stomach. The incidence of gastric blunt rupture is about 0.02%–1.7%, depending on references.1–5 In a series of 227 972 blunt abdominal trauma cases reported by Watts and Fakhry, just 0.5% of patients presented with some gastric lesion and the perforation occurred in 0.02% of all patients.

Bruscagin et al, in a multicentric review of blunt abdominal trauma between 1982 and 1996, found an incidence of 0.6 cases per year, with a mortality of around 27%.6

Besides its low prevalence, because of the fragile gastric wall, a high energy trauma in susceptible patients could spill gastric content into the peritoneum because of the fragile gastric wall. It has been associated with high morbidity and shows why gastric rupture is so dangerous, elevating the risk of death by 2.8 times.6

Due to its rarity and high morbidity and mortality, this report of an atypical presentation report is so important. It could bring more attention to the risk factors, leading to an early recognition and diagnosis and a better management.

Case 1 presentation

A male patient, 20 years old, admitted into the emergency service of Santa Casa de Misericórdia de São Paulo, after being run over by a bus, with high kinetic energy, due to a suicide attempt. In admission, he was haemodynamically stable, with a Glasgow Coma Scale of 14 (open the eyes when asked, spontaneous verbal response and obeying simple commands), with isochoric and pupils reactive to light. The pre-hospital service reported that the patient had a head injury.

In the detailed physical examination of the body segments, he presented multiple abrasions on the face—without any active bleeding, trauma stigma in extremities or perfusion alterations—distended abdomen with painful superficial and deep palpation on the lower region, especially on the left. The rectal examination showed a normotonic sphincter, without palpable bone spicules, topical prostate and blood absence. The other body segments did not present any changes. As a complement to the clinical evaluation, the point of care ultrasound evaluation was performed, using the Focused Assessment with sonography for Trauma protocol, being positive, with the presence of fluid in the hepatorenal window (figure 1).

Figure 1

Mode B ultrasound at Morrison space (Focused Assessment with Sonography for Trauma protocol) showing fluid presence in the cavity (white arrow).

Investigations

Due to his clinical stability, who at the moment had a blood pressure of 120/70 mm Hg, heart rate of 74 bpm and no changes in peripheral perfusion, laboratory tests, arterial blood gases and chest and pelvic X-ray were performed in the emergency room. The exams showed haemoglobin levels of 14.9 mg/dL and platelets of 238 000 cells/mm³; INR 1.16; APTT 29.5 s; sodium 142 mEq/L and potassium 4.1 mEq/L; in arterial blood gas analysis, a pH of 7.29; partial pressure of oxygen (PO₂) 93 cm H₂O and partial pressure of carbon dioxide (PCO₂) 42 cm H₂O; bicarbonate 20.2 mEq/L; BE −6.2; saturation 96%; lactate 3.2 mmol/L; and in X-ray images, only a stable fracture of the left iliac bone. Thus, the patient was referred to full body CT, due to the high kinetic energy involved in the trauma. The CT scan showed the presence of perihepatic fluid and pneumoperitoneum, and grade III splenic laceration, retroperitoneal haematoma in zone II on the left and the presence of stable fracture of the iliac bone (figures 2–4). When we calculate the Injury Severity Score (ISS), we found a score of 25 (abdominal severe injury and extremity serious injury). Exploratory laparotomy was indicated because of the set of findings.

Figure 2

Abdominal CT (the late portal phase) showing pneumoperitoneum and free fluid (*); grade II spleen injury (S); gastric wall thickening (white arrow).

Figure 3

Abdominal CT for pneumoperitoneum assessment, enhanced by the use of lung window (black arrow).

Figure 4

Abdominal CT (the late portal phase) showing the iliac fracture and muscular and fat thickening, associated with local haematoma.

Treatment

As there was no external evident lesion and considering the severity of the trauma, the xiphoid–pubic incision was chosen and, from the beginning, gross contamination of the cavity with food debris and gastric secretion in large quantities was evidenced. When carrying out the inventory of the cavity, a total plane lesion of about 20 cm was found in the posterior wall of the stomach (figure 5). Intraoperative nasogastric probing performed by the anaesthetic team, showing two more anterior wall gastric lesions, only of the serous layer, of approximately 4 cm each, with good vascularisation. Also, splenic laceration was observed near the upper pole, with local bleeding and a zone II retroperitoneal haematoma, associated with oedema close to the duodenum, bowel and colon, without enteric injury.

Figure 5

Gastric posterior wall injury.

Opted by opening the left parietocolic gutter, evidencing the non-expansive and non-pulsatile nature of the retroperitoneal haematoma, followed by omentum release and omentectomy to access the retroperitoneal cavity. Suture of the posterior wall gastric lesion in two planes: total plane with 3–0 vicryl, continuous anchored stitch and seromuscular suture with 3–0 cotton with continuous stitches, and suture of the serous lesions with 3–0 cotton with interrupted stitches (figure 6A), continued with the release of the splenorenal and splenocolic ligament release, spleen dislocation and hilum dissection for splenectomy (figure 6B).

Figure 6

(A) Two planes gastrorraphy final aspect (white arrow); (B) splenectomy product—spleen injury at the superior pole (*).

After splenectomy, exhaustive washing of the abdominal cavity was performed, with at least 8 L of heated saline. It was decided to drain the splenic topography and the gastrorrhaphy region, with silicone tubular drains, externalising them in a single orifice on the left flank, and perihepatic and pelvic drainage, with silicone tubular drains, externalising them in a single orifice on the right flank. Haemostasis was reviewed, and abdominal wall closure was performed in layers, washing the subcutaneous tissue with saline and chlorhexidine.

During the procedure, the patient sustained haemodynamic instability, transfused with 3 red blood cell units, 1 fresh frozen plasma and 3500 mL of crystalloid fluids by the anaesthetic team, and opted to use of vasoactive drugs in the immediate postoperative period, in an intensive care unit. Vasoactive drugs were kept in increasing doses until the second postoperative day, with serous output from the perihepatic drain and haematic from the splenic topography, both with low volume. He remained in intensive care for 4 days. As we achieved the weaning from vasoactive drugs, he could be followed up in a surgical ward.

Outcome and follow-up

The patient maintained antibiotic therapy and acid-blocking with a proton pump inhibitor, followed up with the orthopaedics and psychiatry team in the usage of risperidone. The drains were removed on the 12th (right) and 15th (left) days after surgery and were discharged from the hospital 30 days after the trauma due to psychiatric pending issues, with prior guidance for outpatient follow-up orthopaedic fracture.

Case 2 presentation

A male patient, 31 years old, a victim of a fall from his own height, with low kinetic energy, followed by a thoracic impact on a fixed bulkhead. He was admitted with Glasgow Coma Scale 15 and isochoric and photoreactive pupils, normal physical examination in the primary assessment and haemodynamically stable. In the detailed examination of the body segments, he presented stigmas of thoracoabdominal trauma and chest pain with a pleuritic character, without other features; rectal examination showed normotonic sphincter, without palpable bone spicules, topical prostate and the absence of blood.

Investigations

Due to the patient’s clinical stability and, in this case, low kinetic energy involved, arterial blood gases, chest and pelvic X-ray and total abdomen USG in the radiology sector were performed, according to the hospital protocol. The arterial blood gases showed a pH of 7.39; PO₂ 230 cm H₂O and PCO₂ 38 cm H₂O; bicarbonate 23.0 mEq/L; BE −1.7; saturation 100%; lactate 1.6 mmol/L; and hematocrit 36%. On ultrasound, a spleen with poorly defined limits was found, with the presence of heterogeneous material, predominantly hypoechogenic, in its outline and a moderate amount of free liquid in the abdominal cavity, with the diagnosis of perisplenic haematoma being suggested by the radiology team. With these findings, an abdomen tomography was requested, with visualisation of hypodense areas without enhancement to iodinated contrast, suggesting a splenic laceration and focus of active bleeding in the largest lesion, compatible with splenic lesion grade V7 (figure 7), being referred exploratory laparotomy. The ISS calculated for this patient was 26 (minor external injuries and critical abdominal injury).

Figure 7

Abdominal CT (arterial phase) showing a grade V spleen injury (A), with active bleeding evidenced by the ‘blush’ (white arrow) and the presence of free fluids at Morison’s space and peri-splenic space (late portal phase) (B).

Treatment

Due to the presence of a lesion in the parenchymal viscera that justified the hemoperitoneum and the low kinetic energy of the trauma, the supraumbilical and infraumbilical median incision was chosen. When evaluating the abdominal cavity, a moderate amount of blood was noted, then proceeded with the intestinal loops’ evisceration and four abdominal quadrants tamponation. Large bleeding identified from the splenic hilum, confirming the grade V lesion. It was continued with spleen dislocation and medialisation for splenectomy, with perihilar ligation made with cotton thread 0.

During the haemostasis review, an approximately 5-cm lesion was evidenced in the gastric fundus, with well-vascularised borders and a leak of a large amount of gastric content. Opted for wedge gastrectomy with a linear stapler associated with an invaginating suture in the staple line with an absorbable thread. After the procedure, an exhaustive cavity washing and the splenic topography drainage with a silicone tubular drain were performed, externalising it in an orifice on the left flank. Haemostasis was reviewed, and the abdominal wall was closed by planes.

The procedure was carried out without haemodynamic instability, and the patient received only one red blood cell unit during the surgery, being discharged from the operation room with only antibiotics.

Outcome and follow-up

The patient did not need intensive care, but on the sixth postoperative day, he presented a high volume at splenic topography drain collection, feverish peaks and persistent leucocytosis, even in the absence of young forms of white blood cells. He was requested serum and drain amylase dosage, which was 118 U/L and 187 U/L, respectively.

The investigation of the infectious focus progress and CT showed the presence of a subdiaphragmatic hypoechoic collection. Therefore, guided drainage of the collection was performed, with a 10F Calibre pigtail Skater catheter, with a 360-mL output of a thick, yellowish-looking liquid, without complications, whose analysis revealed amylase dosage of 2258 U/L, configuring a diagnosis of pancreatic fistula.

After drainage, the patient remained hospitalised for 10 days, with subsequent clinical and laboratory improvement and was discharged from the hospital with the Skater drain, with the necessary care guidance. After a week of discharge, he returned to a specialty clinic without new complaints or drainage, which was removed in an outpatient procedure.