Abdominal pain in a patient with a complex history (case report)

Purpose: A 79 yr.-old woman was admitted to our hospital because of amaurosis due to an obliteration of her left central artery and was treated with ASS. 4 days earlier she had had a car crash without any abdominal cutaneous marks.

Material and methods: Laboratory tests showed a significant elevation of the infectious parameters CRP and sedimentation rate as well as antinuclear antibodies. An initial abdominal x-ray showed no abnormalities, the following CT scan pictured thickening of the mesenteric root and, assuming a vasculitic abdominal involvement, the patient was put on steroids, backed up with antibiotics.

Results: As she was complaining of massive constipation and of diffuse abdominal discomfort, an ultrasound exam was performed, which revealed thickened and stiff small bowel loops with normal wall pattern in the right lower quadrant. There was no free air or fluid. The next day the pathological bowel loops were still obvious and there were some agitated loops in the area too. 4 days later the patient developed the clinical and radiological signs of an ileus. Intraoperatively a jejunal perforation was diagnosed. Histologically parts of the omentum maius were hemorrhagic, the intestinal loop gangrenous with purulent serositis and mesenteritis consistent with a massive ischemic damage.

Conclusion: Bowel perforations occur in penetrating and blunt trauma, in children often caused by seat belts. Other described conditions are neoplasias, iatrogenic injury and inflammatory conditions, that penetrate the serosa or adventitia, mostly due to turberculosis and typhoid fever in developing countries.

Imaging features include the presence of free air or fluid, both lacking in our case, segmental wall thickening and stranding of the mesenteric fat.

Diagnosis is often delayed due to the difficulty to establish the diagnosis. In our case the perforation of the jejunal loop might have been multifactorial.