A case of bowel entrapment after penetrating injury of the pelvis: don't forget the omentumplasty
© Ritchie et al; licensee BioMed Central Ltd. 2011
Received: 4 January 2011
Accepted: 10 June 2011
Published: 10 June 2011
Bowel entrapment within a pelvic injury is rare and difficult to diagnose. Usually, it is diagnosed late because of concomitant abdominal injuries. It may present itself as an acute intestinal obstruction or, more commonly, as a prolonged or intermittent ileus. Therefore, one should be aware of this late complication and primarily take measures for avoiding bowel entrapment. This report describes an unusual case of bowel entrapment within a pelvic fracture after a penetrating injury, and discusses options for preventing such a complication.
Bowel entrapment within a pelvic injury is rare and difficult to diagnose. Usually, it is diagnosed late because of concomitant abdominal injuries. It may present itself as an acute intestinal obstruction or, more commonly, as a prolonged or intermittent ileus. Therefore, one should be aware of this late complication and primarily take measures for avoiding bowel entrapment.
Penetrating trauma to the abdomen can cause severe injuries to multiple organs, but entrapment of the bowel within a pelvic fracture is rare.
In case of bowel entrapment in a fracture, there must be a substantial displacement of the fracture and disruption of tissue. Bowel entrapments have been recorded occasionally in sacral, iliac wing and acetabular fractures. A paralytic ileus is a known complication of abdominal surgery and a prolonged recovery is common. However, symptoms can mask true mechanical obstruction. A paralytic ileus occurs in 5.5 to 18 percent of pelvic fractures, lasting an average of 2.6 days [1–3]. Literature shows that the diagnosis is delayed by an average of two weeks, presumably due to difficulty in differentiating entrapment from the more common paralytic ileus. Therefore, entrapment of the small bowel can be easily overlooked when the potential cause of symptoms are not recognized. If an ileus with a pelvic fracture persists for a lengthy period of time, an occult bowel injury such as entrapment at the fracture site should be considered. Radiological techniques can be useful in making the diagnosis. Plain radiographs can be helpful in identifying obstructions. Oral contrast studies can be misleading due to normal transit times for the passage of contrast, even in case of a herniated bowel. A CT scan with enteric contrast can demonstrate a herniated or entrapment bowel in the fracture [4, 5].
To treat the problem and avoid recurrent obstruction an omentoplasty was performed to seal the pelvic cavity. The use of the greater omentum in the pelvic cavity was first described for repair of fistulas in the genitourinary tract. Since then, different use of omentum have been promoted in healing in a range of applications including closure of peptic ulcers, management of empyemas, infected thoracotomy wounds and wounds following excision of radionecrosis [6, 7]. In our case, the fractured sacral bone created a "dead space" as seen also in case of perineal wounds and/or the presence of a presacral dead space after an abdominoperianeal resection. We prefer filling the "dead space" with an omentumplasty, above a bonegraft filling, as we were performing a laparotomy. Although an autologic bonegrafting is optional. The use of the omentum exludes the small intestine from the pelvic area, and should have been performed primarily to prevent the bowel entrapment.
Bowel entrapment within a pelvic fracture is rare and hard to diagnose. Usually, it is diagnosed late because of concomitant abdominal injuries. To prevent the problem and avoid recurrent obstruction an omentoplasty should be performed to seal the pelvic cavity during the primary procedure.
There was informed consent of the patient obtained for publication of this case report and accompanying images.
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