Case 4: Pneumoperitoneum in a 2-year-old Boy

Patient Course

The working diagnosis and concern at this time is perforated appendicitis and septic shock. In the operating room, on entering the peritoneal cavity there is immediate return of dark sanguineous fluid. Inspection of the small bowel reveals several areas of chronic serosal defects of the underlying submucosa at various stages of healing as well as an area of perforation in the ileum with associated adhesions, mucosal transmural hematomas, and a defect in the mesentery. In addition, a mesenteric hematoma is noted distally in the bowel. The appendix is visualized and is normal in appearance, as is the colon. A small-bowel resection with primary anastomosis is performed, with postoperative diagnoses of hemoperitoneum and perforated ileum without a clear mechanism.

Actual Diagnosis

The patient is then brought to the PICU, where pediatric surgery expresses concern regarding the traumatic appearance of his internal injuries. The patient is reexamined and again noted to have small and subtle, but multiple, abrasions to his face and extremities as well as bruising above his sacrum. A nonaccidental trauma (NAT) evaluation is subsequently pursued with an ophthalmologic evaluation, skeletal survey, and CT scan of the child’s head. A dilated eye examination is negative for vitreous or intraretinal hemorrhages, and there is no evidence of skull fracture on the CT scan. However, on the skeletal survey the patient has numerous areas concerning for healing fractures, including new bone formation at the left midclavicle, fraying at the proximal humeral metaphysis (Fig 3), and distortion of the lateral condylar region of the distal left humerus suggestive of metaphyseal fractures. These findings in concert with his malnourished appearance, skin findings, and ileal perforation without a clear mechanism prompt an immediate Department of Children and Family Services referral, and the patient is placed on a hospital hold, which in Los Angeles County is a temporary legal decision in which a child is effectively detained from the custody of a parent or guardian.

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Figure 3.

Skeletal survey revealing findings consistent with metaphyseal fractures in the left humerus.

The Condition

NAT “child physical abuse” can be very difficult to differentiate from other disease processes and, therefore, often requires a particularly high index of suspicion. Although cases of small-bowel injury caused by NAT have been described in the pediatric literature, this is the first case reported of NAT resulting in ileal perforation in a pediatric patient. The incidence of abdominal injury in NAT ranges from 0.5% to 4%. However, it accounts for up to 50% of fatalities from abuse. (1)(2)

As illustrated in the case described herein, the presentation can pose a diagnostic challenge. For example, less than 12% of patients with abusive abdominal injury have abdominal bruising. (1)(2) However, there are certain characteristics, such as time to presentation, injury severity, and age of the patient, that are more characteristic of NAT as opposed to accidental trauma. Unlike accidental trauma, NAT is often associated with a delay in presentation and higher injury severity. (3) In addition, duodenal and jejunal injuries are more consistent with NAT compared with abdominal trauma sustained as a result of falls. (4) Duodenal injuries, in particular, should alert clinicians to NAT. In 2 separate studies from level 1 pediatric trauma centers, 100% of children younger than 2 and 4 years, respectively, who presented with duodenal injury were victims of NAT. (1)(3)(5) Children are more susceptible to severe abdominal injuries due to poorly developed abdominal musculature and small anteroposterior diameters, thereby placing intra-abdominal organs at higher risk for injury.

The Outcome

The patient remains hospitalized postoperatively for management of pain and hypertension of unknown etiology, as well as to ensure that he is able to tolerate nutrition by mouth. He is ultimately discharged to the care of a foster family (who had also cared for him from birth until 18 months of age, when he was briefly reunited with his biological parents for 8 months until his hospitalization) after being admitted for more than 2 weeks. His 2 siblings are also placed with this foster family. On follow-up with pediatric surgery, pediatric nephrology, and nutrition, the patient is reported to be doing well aside from occasional nightmares and combative behavior during mealtimes. Review of his growth chart reveals excellent catch-up weight gain since discharge (11.8 kg, 13th percentile, z score: –1.1).

Lessons for the Clinician

• In the case of a young child presenting with hollow viscus injury without clear trauma as a cause and with a delay in presentation, nonaccidental trauma should be considered.

• Although abdominal injury is a less common presentation of nonaccidental trauma, it carries the second highest mortality rate and should be considered in children presenting with other abusive injuries. (6)

• Children with abusive abdominal injuries often do not have external findings such as bruising. (1)(2)

• A thorough skin examination is critical in the evaluation of a child who presents for medical attention, especially when the history is not consistent with the physical findings.