A case of non-accidental injury with ileal perforation

Introduction

Diagnosis of internal abdominal injuries in abused children is challenging (Kondolot, M et al., Pediatr Emerg Care 2011; 27: 1075–1077). Although abdominal injuries in abused children are rather uncommon (2–3% of all injuries), blunt abdominal trauma is the second most common cause of death in maltreated children following brain injuries (Yavuz MS et al., J Forensic Leg Med 2008;15 (4): 259–262). Early diagnosis is the most important factor to reduce mortality (Beckmann KR., J Am Osteopath Assoc 2000; 100 (8): 496–497). In the rare cases of bowel perforation associated with non-accidental trauma, the most common sites are the proximal parts of the small bowel (duodenum and jejunum). The cause of perforation in the proximal parts of the small bowel is most likely due to midline compression of the bowel between a blunt force and the spine (Kato H et al., Acute Med Surg 2020; 7 (1): e541). To our knowledge, we present the first case report in literature of an ileal perforation due to child maltreatment.

Case

A 4-year-old girl was referred to our department of pediatric surgery for suspected non-accidental injury accompanied by a lesion of the liver or spleen. Two days before, the mother and the child had presented to an external hospital because of a chin laceration, which was treated with primary wound closure. At this point, a full body examination was not performed. The alleged cause was a fall down the stairs. One day later, they presented to the hospital again because of abdominal pain. An ultrasound showed free fluid inside the abdominal cavities. The girl was referred to our clinic with suspected non-accidental injury and abdominal blunt trauma. At arrival the girl showed signs of “frozen watchfulness” and gave no information about the circumstances of the accident, although her speech development was age-appropriate. Furthermore, the child did not express herself spontaneously.

Physical examination showed multiple hematomas on her face, back, right foot, both knees and her abdomen (3x3cm lower right abdomen) and stripe-shaped hematomas matching fingerprints in the gluteal region on both sides. There was tenderness in the lower abdomen. Vital signs were stable. The girl vomited several times and had no fever. The laboratory revealed elevated leucocytes (20.9 10³/µl) and CRP (23 mg/dl), hemoglobin was stable (11.8 g/dl). Ultrasound was performed and confirmed free fluid in the Koller pouch and an intestinal loop in the right lower abdomen without peristalsis. In an abdominal CT scan perforated appendicitis was suspected ([Fig. 1]). In light of laboratory results, clinical examination as well as radiological findings, we performed laparoscopy. Intraoperative findings showed an inconspicuous appendix, but several hematomas of the mesentery of the small bowel, one superficial lesion of the serosa of the jejunum and a perforation sized 1x2 cm of the terminal ileum approximately one centimeter before Bauhinʼs valve ([Fig. 2] [3]). We converted to right lower laparotomy and performed a closure of the defect with absorbable sutures. Postoperatively, the girl was monitored in the pediatric intensive care unit. The child protection team was consulted and law enforcement was informed. In conversation with social services the mother admitted that her partner had abused the child and that injuries were not due to falling the stairway. The girl was placed in custody of foster parents.

Fig. 1 Abdominal CT scan suggesting perforated appendicitis.

Fig. 2 Defect size of the perforation.

Fig. 3 Perforated terminal ileum.

Our patient recovered quickly from surgery and was discharged after 11 days. Two days later the girl was admitted again with abdominal pain and vomiting. Clinical examination and X-ray showed obstructive ileus. Re-laparotomy was performed and obstructive adhesions localized at the former perforation site were removed. The girl recovered again and could be discharged after five days.

Publication History

Article published online:
06 May 2025