Traumatic prepyloric transection: unusual injury in a child
Liesel H. Whytea, S.V.S. Soundappanb,*, John Harveyc, Daniel T. Cassb
aDepartment of Pediatrics, University of Sydney, Sydney, NSW 2145 Australia
bDepartment of Academic Surgery and Trauma, The Children’s Hospital at Westmead, Westmead, Sydney,
NSW 2145, Australia
cDepartment of Surgery, The Children’s Hospital at Westmead, Westmead, Sydney, NSW 2145, Australia
Abstract The diagnosis and management of a 14-year-old girl with isolated traumatic transection of the
prepylorus after a motor vehicle accident are presented. Abdominal computed tomography was useful in
the diagnosis of pneumoperitoneum associated with hollow viscous injury. Rapid diagnosis and surgical
repair of this unusual injury resulted in an uncomplicated recovery.
D 2006 Elsevier Inc. All rights reserved.
There are few reported cases of isolated gastric rupture
after blunt abdominal trauma, especially in children. In
1998, Allen et al  conducted a review of almost 20000
blunt trauma admissions over a 9-year period (2550 were
14 years or younger). They found that although the predom-
inant mechanism for blunt hollow viscous injury (HVI) was
a motor vehicle accident (MVA; 55.6%), only 27 children
(1.1%) in an MVA sustained an HVI. Those 27 children
sustained a total of 30 HVIs, of which only 1 was a gastric
injury . We report a case of seat-belt prepyloric
transection sustained in a medium-speed MVA.
1. Case report
A 14-year-old girl was involved in a head-on MVA at a
speed of approximately 60 km/h. She was restrained by a
lap belt in the middle of the rear seat and trapped in the car
for 30 minutes before being freed.
The patient was hemodynamically stable but complained
of abdominal pain. She had visible bruising from the seat
belt to the anterior abdominal wall. She remained hemody-
namically stable en route to the emergency department,
although she was slightly hypertensive, with a mean
noninvasive blood pressure of 100 mm Hg.
Upon arrival at the emergency department, the patient
complained of nausea and had one episode of vomiting
(food residue). An orogastric tube was passed, and a small
quantity of dark blood was aspirated. A urinary catheter
drained a moderate amount of urine, which was clear. On
examination, the patient’s abdomen was tender in all
quadrants, with guarding. Bowel sounds were not heard.
Lateral cervical spine and chest x-ray findings were reported
as normal, but a pelvic x-ray revealed a fracture of the L1
transverse process on the left side (but no Chance fracture).
In view of the abdominal bruising, tenderness, guarding,
and the mechanism of injury, an abdominal computed
tomographic (CT) scan with intravenous contrast was
organized. The CT scan revealed the presence of free gas
in the abdomen, an indication of perforation of a hollow
viscous. Free fluid in Morrison’s pouch and in the pelvis
was also demonstrated. The pancreatic margins were not
sharply delineated, possibly indicating a traumatic pancre-
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* Corresponding author. Tel.: +61 2 9845 0000; fax: +61 2 9845 3346.
E-mail address: firstname.lastname@example.org (S.V.S. Soundappan).
Journal of Pediatric Surgery (2006) 41, E23–E24
atic injury. An incidental finding of a horseshoe kidney was Download full-text
also made at this time.
At laparotomy, approximately 4 hours postinjury, a
completely transected prepylorus was found, along with a
small duodenal-jejunal serosal tear. No other injury was
found. The free ends of the transected prepylorus were
debrided and an end-to-end anastomosis was performed.
The abdominal cavity was washed out with warm saline.
The patient’s postoperative course was uneventful, apart
from a peak lipase reading of 968 U/L on day 2, correlating
with the CT report of possible pancreatic injury. An upper
gastrointestinal contrast study 8 days after the operation was
unremarkable, and the patient subsequently tolerated the
introduction of a full diet well. The L1 transverse process
fracture was managed conservatively, with no mobility
restriction. The patient was discharged from the hospital
12 days postoperatively. A barium meal 6 weeks after the
accident showed no abnormality in the pyloric and duodenal
regions. At the 3-month follow-up visit, the patient had no
complaint and was tolerating an unrestricted diet.
Seat-belt stomach transection is a very rare injury ,
especially in children. According to Nanji and Mock ,
most cases occur in the setting of motor vehicle trauma and
the diagnosis is usually made at laparotomy, although the
advent of CT scanners in the last decade has meant an
increase in the preoperative diagnosis of pneumoperitoneum
associated with HVI .
When gastric rupture does occur in blunt trauma, it often
does so in the context of a full stomach at the time of impact
and adjacent solid organs, thoraces, and extremities fre-
quently sustain associated injuries . It is uncommon for
an isolated HVI to occur, especially a complete prepyloric
transection as described in this case. A similar case was de-
scribed by Carragher and Cranley  involving a 20-year-old
woman who was a front-seat passenger in a head-on collision
and whose stomach was found to be completely transected
just proximal to the pylorus. Her survival was reported as the
first known case of its kind and was associated with a Chance
vertebral fracture of the second lumbar vertebra. It would
appear that in her case, as in the case reported here, prompt
surgical intervention (laparotomy) was the key to survival
and subsequent complete recovery. Indeed, delay in diag-
nosing HVI is associated with increased morbidity and
Unfortunately, accurate and rapid diagnosis of HVI in
children is difficult . Although the cornerstone of the
evaluation of a hemodynamically stable patient involved in
blunt trauma has become CT (with either oral or intravenous
contrast) [8,9], it has been suggested that this modality is not
sufficiently sensitive to detect HVIs reliably. Interpretation
of subtle CT findings suggestive of HVI appears to be
observer dependent, and HVI may be missed in up to 50%
of patients. It is also commonly understood that radiological
evidence of perforation (pneumoperitoneum) is often
absent. Brown et al  reported that only 19% of the
cases they reviewed were shown to have free air in the
peritoneum on abdominal x-ray, and Chatterjee and Jagdh-
ish  reported a rate of only 25% patients positive for
pneumoperitoneum on x-ray. Diagnostic peritoneal lavage is
sometimes performed , but rarely in a pediatric setting
and again is considered too nonspecific for a diagnosis of
HVI. In our case, pneumoperitoneum was not detected on
plain x-ray but was on CT. It would appear that a
combination of imaging, repeated clinical examination
(especially abdominal tenderness, abdominal wall bruising,
and hemodynamic status), and history taking of the injury is
the most consistently reliable way to detect HVI and
proceed to laparotomy.
Isolated gastric rupture in children is rare, and diagnosis
may present a challenge. However, as illustrated by our case,
the combination of a high degree of suspicion for HVI owing
to the mechanism of injury, the clinical findings of
abdominal tenderness and bruising, and the demonstration
of pneumoperitoneum on CT all resulted in a very early
surgical intervention and a favorable outcome for the patient.
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L.H. Whyte et al.E24