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Luna-Álvarez RD, Navarro-Pimiento DC, Alarcón-Carvajal YF, Naranjo-Soler AJ. Case report emphasize pearls of duodenal perforation. Int J Surg Case Rep 2023; 110:108615. [PMID: 37647753 PMCID: PMC10509796 DOI: 10.1016/j.ijscr.2023.108615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Isolated duodenal perforation secondary to trauma is a rare abdominal surgical condition, with a questionable surgical approach depending on the case. PRESENTATION OF CASE This is a case report of a 27-year-old male patient who presented with a free perforation in the posterior wall of the third portion of the duodenal frame and secondary retropneumoperitoneum without injuring any contiguous organ, after a medium-impact blunt abdominal trauma during a soccer game. DISCUSSION A laparotomy was performed, followed by duodenorraphy with Connell-Mayo suture and Lambert suture using vascular prolene in two planes. A nasogastric tube was placed up to the jejunum, and a Jackson-Pratt drain was placed in close to the duodenum next to the sutures. During hospitalization was found a positive bacterial culture of the peritoneal fluid hence received antibiotics, without complication. CONCLUSION It is essential to make a timely diagnosis with its respective individualized surgical approach and it must be managed as an emergency surgical procedure.
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Otiv M, Shrotriya S, Mutha S. Duodenal Perforation - Unusual Presentation of Multisystem Inflammatory Syndrome. Indian J Pediatr 2023; 90:633. [PMID: 37081254 PMCID: PMC10119007 DOI: 10.1007/s12098-023-04549-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/02/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Madhumati Otiv
- Department of Pediatric Intensive Care, KEM Hospital, Rasta Peth, Pune, 411011, India.
| | - Shashank Shrotriya
- Department of Pediatric Surgery, KEM Hospital, Rasta Peth, Pune, 411011, India
| | - Sourabh Mutha
- Department of Pediatric Intensive Care, Shripal Hospital, Baramati Bhigwan Road, Baramati, 413102, India
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Zakarya AH, Mouna L, Loubna A, Houda O, Mounir E, Fouad E, Hicham Z. Duodenal Trauma in Children: What is the Status of Non-Operative Conservative Treatment? Glob Pediatr Health 2023; 10:2333794X231156057. [PMID: 36992845 PMCID: PMC10041607 DOI: 10.1177/2333794x231156057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/17/2023] [Indexed: 03/28/2023] Open
Abstract
Conservative treatment of duodenal trauma in children has long been the first line of treatment for duodenal wall hematomas. However, it has rarely been described in duodenal perforations. Our purpose is to highlight the possibility of conservative treatment in selected cases of duodenal perforation. In the period between 2009 and 2022, 6 children were treated for duodenal injury following abdominal blunt trauma in the pediatric surgical emergency department. The clinical presentation, diagnosis and treatment are reported and analyzed. Three patients presented with duodenal hematomas, they were treated non-operatively with hospital stays between 12 and 20 days and good clinical outcome. One child presented with duodenal hematoma and retroperitoneal air bubbles; non-operative conservative treatment was carried with favorable results. The fifth patient had a duodenal perforation; he underwent a primary duodenal 2-layers closure. The last patient had a combination of duodenal hematoma and perforation involving 75% of the duodenal diameter for which he underwent a gastro-jejunostomy with pyloric exclusion. An isolated duodenal lesion can be subject to a conservative treatment whenever allowed by a stable clinical condition and the availability of appropriate clinical and radiological monitoring.
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Affiliation(s)
- Alami Hassani Zakarya
- Faculty of medicine and pharmacy of Rabat, Mohamed V University, Rabat, Morocco
- Zakarya Alami Hassani, Surgical Pediatric Emergency Department, Children’s Hospital, Faculty of Medicine and Pharmacy, Mohamed V University, Rue Mohamedia, Immeuble No. 14, Appartment No. 3, Hassan, Rabat 10100, Morocco.
| | - Lazrak Mouna
- Faculty of medicine and pharmacy of Rabat, Mohamed V University, Rabat, Morocco
| | - Aqqaoui Loubna
- Faculty of medicine and pharmacy of Rabat, Mohamed V University, Rabat, Morocco
| | - Oubejja Houda
- Faculty of medicine and pharmacy of Rabat, Mohamed V University, Rabat, Morocco
| | - Erraji Mounir
- Faculty of medicine and pharmacy of Rabat, Mohamed V University, Rabat, Morocco
| | - Ettayebi Fouad
- Faculty of medicine and pharmacy of Rabat, Mohamed V University, Rabat, Morocco
| | - Zerhouni Hicham
- Faculty of medicine and pharmacy of Rabat, Mohamed V University, Rabat, Morocco
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Manan MR, Rahman S, Komer L, Manan H, Iftikhar S. A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children. Cureus 2022; 14:e27276. [PMID: 36039273 PMCID: PMC9404682 DOI: 10.7759/cureus.27276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/23/2022] [Indexed: 11/05/2022] Open
Abstract
Child abuse is a preventable phenomenon of considerable concern resulting in significant child mortality and morbidity. We analyze various abuse lesions such as radiological (visceral and skeletal lesions and those associated with head trauma) and cutaneous (burns, bruises, bites, etc.) to enhance streamlined identification of injuries in cases of physical child abuse. For effective results, it is essential to remain mindful of all background factors, such as the caregiver setting and the prevalence of child maltreatment in the concerned community while acknowledging the possibility of natural causes (genetic diseases such as osteogenesis imperfecta and hemophilia, or acquired abnormalities) that can mimic NAT and cause confusion in diagnosis and treatment. The margin of error in cases of abuse is negligible, therefore, making its diagnosis a momentous as well as challenging clinical task. An ineffective diagnosis can have detrimental emotional consequences for the family and may even expose the child to future potentially fatal episodes of abuse. Hence, there is a need to direct special focus on the importance of accurate history taking and immediate, responsible reporting to authorities, as well as to child protective services. Therefore, considering the multifactorial approach this subject requires, this review aims to delve into prevalence statistics, various risk factors, and their effect on psychological health to offer a near-complete regulation to ensure an effective understanding of NAT on part of doctors, social workers, and other relevant authorities.
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Affiliation(s)
| | - Sara Rahman
- Basic Sciences, Services Institute of Medical Sciences, Lahore, PAK
| | - Leah Komer
- Psychiatry, University of Toronto, Toronto, CAN
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Large Duodenal Hematoma Causing an Ileus after an Endoscopic Duodenal Biopsy in a 6-Year-Old Child: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2021; 58:medicina58010012. [PMID: 35056320 PMCID: PMC8780155 DOI: 10.3390/medicina58010012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/17/2021] [Accepted: 12/17/2021] [Indexed: 01/07/2023]
Abstract
Intramural duodenal hematoma (IDH) in children is a rare complication after esophagogastroduodenoscopy. It is commonly described in patients with additional disorders or risk factors, such as coagulopathy. We present a case of a previously healthy 6-year-old boy with a large obstructing intramural duodenal hematoma and concomitant pancreatitis after an elective esophagogastroduodenoscopy. The patient presented with typical symptoms of an IDH, such as abdominal pain and distension, nausea and vomiting. IDH was diagnosed using ultrasound and magnetic resonance imaging examination. Conservative management with gastric decompression using a nasogastric feeding tube, bowel rest, total parenteral nutrition and analgesia was performed. After three weeks, the patient was discharged from the hospital without any complaints. Interventional management of IDH in pediatric patients with a lack of response to conservative therapy or complicating IDH should be discussed in an interdisciplinary team.
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6
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Loos MLHJ, Bakx R, Duijst WLJM, Aarts F, de Blaauw I, Bloemers FW, Ten Bosch JA, Evers M, Greeven APA, Hondius MJ, van Hooren RLJH, Huisman E, Hulscher JBF, Keyzer-Dekker CMG, Krug E, Menke J, Naujocks T, Reijnders UJL, de Ridder VA, Spanjersberg WR, Teeuw AH, Theeuwes HP, Vervoort-Steenbakkers W, de Vries S, de Wit R, van Rijn RR. High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands. Forensic Sci Med Pathol 2021; 17:621-633. [PMID: 34773580 PMCID: PMC8629892 DOI: 10.1007/s12024-021-00416-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
Purpose Between 0.1—3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. Methods This is a retrospective study that included children (0–18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. Results The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66–12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. Conclusion One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children. Supplementary information The online version contains supplementary material available at 10.1007/s12024-021-00416-7.
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Affiliation(s)
- Marie-Louise H J Loos
- Amsterdam UMC, Department of Paediatric Surgery, Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Roel Bakx
- Amsterdam UMC, Department of Paediatric Surgery, Emma Children's Hospital, Paediatric Surgical Centre Amsterdam, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wilma L J M Duijst
- Department of Forensic Medicine, GGD IJsselland, Zwolle, the Netherlands
- Criminal Law and Criminology, Faculty of Law, Maastricht University, Maastricht, the Netherlands
| | - Francee Aarts
- Department of Forensic Medicine, GGD Nijmegen, Nijmegen, the Netherlands
| | - Ivo de Blaauw
- Department of Paediatric Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Jan A Ten Bosch
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martina Evers
- Department of Forensic Medicine, GGD Euregio, Enschede, the Netherlands
- Department of Surgery, Haga Teaching Hospital & Juliana Children's Hospital, The Hague, the Netherlands
| | | | | | | | - Erik Huisman
- Department of Forensic Medicine, GGD Haaglanden, The Hague, the Netherlands
- GGD Hollands-Midden, Department of Forensic Medicine, Leiden, the Netherlands
| | - Jan B F Hulscher
- Department of Surgery, Division of Paediatric Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Claudia M G Keyzer-Dekker
- Erasmus Medical Centre, Department of Paediatric Surgery, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Egbert Krug
- Department of Trauma Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jack Menke
- Forensisch Artsen Rotterdam-Rijnmond' (FARR), Rotterdam, the Netherlands
| | - Tatjana Naujocks
- GGD Groningen, Department of Forensic Medicine, Groningen, the Netherlands
| | - Udo J L Reijnders
- Department of Forensic Medicine, GGD Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Victor A de Ridder
- Department of Paediatric Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Arianne H Teeuw
- Amsterdam UMC, Department of Social Paediatrics, Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Hilco P Theeuwes
- Department of Trauma Surgery, Elizabeth TweeSteden Hospital, Tilburg, the Netherlands
| | | | - Selena de Vries
- Department of Forensic Medicine, Section On Forensic Paediatrics, Netherlands Forensic Institute, The Hague, The Netherlands
| | - Ralph de Wit
- Department of Trauma Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Rick R van Rijn
- Department of Forensic Medicine, Section On Forensic Paediatrics, Netherlands Forensic Institute, The Hague, The Netherlands
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Center for Forensic Science and Medicine, Amsterdam, The Netherlands
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7
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Goh B, Soundappan SSV. Traumatic duodenal injuries in children: a single-centre study. ANZ J Surg 2020; 91:95-99. [PMID: 33369841 DOI: 10.1111/ans.16502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/07/2020] [Accepted: 11/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries. METHODS Retrospective review was conducted over a 16-year period from a single paediatric trauma centre. RESULTS Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified. CONCLUSION In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.
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Affiliation(s)
- Barnabas Goh
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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8
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Kato H, Mitani Y, Goda T, Watanabe T, Kubota A, Yamaue H. A case of pediatric duodenal transection caused by abuse successfully treated by duodenojejunostomy. Acute Med Surg 2020; 7:e541. [PMID: 32685176 PMCID: PMC7358249 DOI: 10.1002/ams2.541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/23/2020] [Accepted: 06/03/2020] [Indexed: 11/28/2022] Open
Abstract
Background Abuse can be a cause of pediatric duodenal injury. Patients who have been injured by abuse tend to have delay before medical examination, they may therefore have especially poor prognosis. Case presentation A 3‐year‐old boy presented with abdominal pain and was diagnosed with duodenal perforation. He was urgently transferred to our hospital for surgery. There was no clear history of trauma according to initial parent interviews, but old bruises were observed in several places. Paternal remarks about the injury mechanism were contradictory to bruit findings. Eventually, the mother reported daily paternal domestic violence against the patient. Duodenal perforation was considered to be caused by physical abuse, and emergent surgery was carried out. Intraoperative findings revealed transection at the horizontal part of the duodenum. Primary repair was difficult due to severe damage, so duodenojejunostomy was undertaken. Conclusion Duodenojejunostomy was successfully carried out as emergent surgery for severely damaged duodenal transection.
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Affiliation(s)
- Hirotaka Kato
- Second Department of Surgery Wakayama Medical University Wakayama Japan
| | - Yasuyuki Mitani
- Second Department of Surgery Wakayama Medical University Wakayama Japan
| | - Taro Goda
- Second Department of Surgery Wakayama Medical University Wakayama Japan
| | - Takashi Watanabe
- Second Department of Surgery Wakayama Medical University Wakayama Japan
| | - Akio Kubota
- Second Department of Surgery Wakayama Medical University Wakayama Japan
| | - Hiroki Yamaue
- Second Department of Surgery Wakayama Medical University Wakayama Japan
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Canty K, Patel ND, Im DD. Case 4: Pneumoperitoneum in a 2-year-old Boy. Pediatr Rev 2020; 41:90-92. [PMID: 32005688 DOI: 10.1542/pir.2018-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Daniel D Im
- Division of Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
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10
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Abstract
PURPOSE To examine surgical outcomes of children with pancreaticoduodenal injuries at a Quaternary Level I pediatric trauma center. METHODS We queried a prospectively maintained trauma database of a level one pediatric trauma center for all cases of pancreatic and/or duodenal injury from 2002 to 2017. Analysis was conducted using JMP 13.1.0. RESULTS 170 children presented with pancreatic and/or duodenal injury. 13 (7.7%) suffered a combined injury and this group forms the basis for this report with mean ISS of 22.8 (± 15.1), RTS2 of 6.4(± 2.1), and median age of 6.6 (1.3-13.5) years. Child abuse (31%) and bicycle injuries (23%) were the most common mechanisms. 8/13 (61.5%) required operative intervention. Higher AAST pancreatic and duodenal injury grade (2.9 vs. 1.2, p = 0.05 and 3.6 vs. 1.4, p = < 0.01), lower RTS2 (7.84 vs. 5.49, p < 0.01), and lower GCS (9.6 vs. 15, p = 0.03) predicted operative intervention. 6/8 (75%) undergoing surgery survived to discharge with only (2/6) survivors suffering postoperative complications. Both mortalities were secondary to severe traumatic brain injury. CONCLUSION Surgical management of complex pancreaticoduodenal injury is an uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.
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11
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Walker AE. The Adult Pancreas in Trauma and Disease. Acad Forensic Pathol 2018; 8:192-218. [PMID: 31240039 PMCID: PMC6490126 DOI: 10.1177/1925362118781612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022]
Abstract
The spectrum of traumatic and natural disease that can affect the adult pancreas is multiple and varied. Some entities are more commonly encountered in routine forensic pathology practice and the forensic pathologist needs to be very familiar with their pathological features and development from a pathophysiological perspective. However, many of the conditions are extremely rare and may never be encountered in the professional lifetimes of an individual pathologist. Still, forensic pathologists need to be aware of them in case they are one day faced with these entities as possible diagnoses to be established at postmortem examination. This can be the result of clinical concerns raised in life, potential natural disease explanations for unexpected biochemical results, and sudden, unexpected or otherwise unexplained deaths where criminal concern about the exogenous administration of a substance must be considered. Acad Forensic Pathol. 2018 8(2): 192-218.
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Affiliation(s)
- Alfredo E. Walker
- Alfredo E. Walker, MBBS, 501 Smyth Road, Ottawa ON K1 H 8L6, Canada.
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12
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Malik A, Faerber EN. Pediatric abdominal and pelvic imaging in non-accidental trauma. APPLIED RADIOLOGY 2018. [DOI: 10.37549/ar2473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. J Trauma Acute Care Surg 2017; 82:1147-1157. [DOI: 10.1097/ta.0000000000001441] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Affiliation(s)
- Carol D Berkowitz
- From the Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA
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16
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Chang YC, Huang JL, Hsia SH, Lin KL, Lee EP, Chou IJ, Hsin YC, Lo FS, Wu CT, Chiu CH, Wu HP. Child protection medical service demonstration centers in approaching child abuse and neglect in Taiwan. Medicine (Baltimore) 2016; 95:e5218. [PMID: 27858867 PMCID: PMC5591115 DOI: 10.1097/md.0000000000005218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Child abuse includes all forms of physical and emotional ill treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child's health, development, or dignity. In Taiwan, the Child Protection Medical Service Demonstration Center (CPMSDC) was established to protect children from abuse and neglect. We further analyzed and compared the trends and clinical characteristics of cases reported by CPMSDC to evaluate the function of CPMSDC in approaching child abuse and neglect in Taiwan. We prospectively recorded children with reported child abuse and neglect in a CPMSDC in a tertiary medical center from 2014 to 2015. Furthermore, we analyzed and compared age, gender, scene, identifying settings, time of visits, injury type, injury severity, hospital admission, hospitalization duration, and outcomes based on the different types of abuse and the different settings in which the abuse or neglect were identified. Of 361 child abuse cases (mean age 4.8 ± 5.36 years), the incidence was highest in 1- to 6-year-old children (n = 198, 54.85%). Physical abuse and neglect were predominant in males, while sexual abuse was predominant in females (P < 0.001). Neglect was most common (n = 279, 75.85%), followed by physical (n = 56, 15.51%) and sexual abuse (n = 26, 7.2%). The most common identifying setting was the emergency department (n = 320, 88.64%), with neglect being most commonly reported. Head, neck, and facial injuries were more common in physically abused children than in neglected and sexual abused children (P < 0.005), leading to longer hospitalization (P = 0.042) and a higher Injury Severity Score (P = 0.043). There were more skin injuries in neglect (P < 0.001). The mortality rate was 2.49% (n = 9). The CPMSDC could enhance the ability, alertness, and inclination of professionals to identify suspected cases of child abuse, and to increase the rate of registry. Cases of physical abuse had a higher Injury Severity Score, longer duration of hospitalization, and more injuries of head, face, and neck compared with other types of abuse. The reported rate of neglect was highly elevated after the CPMSDC established during the study period. Recognition of neglect is not easy, but the consequent injury, especially asphyxia, may lead to mortality.
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Affiliation(s)
- Yu-Ching Chang
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan
- College of Medicine, Chang Gung University
| | - Jing-Long Huang
- College of Medicine, Chang Gung University
- Division of Pediatric Allery, Asthma, and Rheumatology, Department of Pediatrics
| | - Shao-Hsuan Hsia
- College of Medicine, Chang Gung University
- Division of Pediatric Critical Care Medicine, Department of Pediatrics
| | - Kuang-Lin Lin
- College of Medicine, Chang Gung University
- Division of Pediatric Neurology, Department of Pediatrics
| | - En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics
| | - I-Jun Chou
- College of Medicine, Chang Gung University
- Division of Pediatric Neurology, Department of Pediatrics
| | - Yi-Chen Hsin
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan
- College of Medicine, Chang Gung University
| | - Fu-Song Lo
- College of Medicine, Chang Gung University
- Divsion of Pediatric Endocrinology, Department of Pediatrics
| | - Chang-Teng Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan
- College of Medicine, Chang Gung University
| | - Cheng-Hsun Chiu
- College of Medicine, Chang Gung University
- Division of Pediatric infectious diseases, Department of Pediatrics
| | - Han-Ping Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan
- College of Medicine, Chang Gung University
- Correspondence: Han-Ping Wu, Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan, No. 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan (e-mail: )
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17
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Ultrasound of the duodenum in children. Pediatr Radiol 2016; 46:1324-31. [PMID: 27003134 DOI: 10.1007/s00247-016-3564-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/06/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
Abstract
Ultrasound is well suited for examining the pediatric duodenum, given the small size of the patients, the lack of ionizing radiation and high-resolution imaging potential. Technical considerations, normal anatomy, congenital and acquired pathology of the duodenum, and the advantages and limitations of US are discussed and illustrated in this review.
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18
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Hartman S, Petroze R, McGahren E. Two Cases of Abdominal Pain after Trauma. Pediatr Rev 2016; 37:e16-8. [PMID: 27037109 DOI: 10.1542/pir.2015-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Stephanie Hartman
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Robin Petroze
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Eugene McGahren
- Department of Surgery, University of Virginia, Charlottesville, VA
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Carter KW, Moulton SL. Pediatric abdominal injury patterns caused by "falls": A comparison between nonaccidental and accidental trauma. J Pediatr Surg 2016; 51:326-8. [PMID: 26850907 DOI: 10.1016/j.jpedsurg.2015.10.056] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND/PURPOSE Falling from a low height is the most common history given by caregivers of pediatric nonaccidental trauma (NAT) victims evaluated for blunt abdominal trauma (BAT). The purpose of this study is to compare the patterns of injuries seen in children with BAT who are victims of NAT with those seen after a fall-related incident. METHODS Trauma database query from regional pediatric trauma centers identified patients were who were evaluated for BAT resulting from either NAT or a fall. Study groups included patients younger than five years who were (1) victims or NAT, or (2) fall casualties. RESULTS Sixty-five NATs and 115 fall casualties were identified. NAT victims had higher ISS, had more severe head injuries according to AIS scores, had more hollow viscus injuries, and had more pancreatic injuries. Fall casualties were more likely to have solid organ injuries. CONCLUSIONS When evaluating children with a history of blunt abdominal trauma caused by a fall, suspicion for NAT is warranted if the child is younger than five years, has a hollow viscus, pancreatic, and/or severe head injury and has a high ISS. Likewise, isolated splenic or renal injury allays suspicion for NAT.
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Affiliation(s)
- Kyle W Carter
- University of Colorado School of Medicine, Aurora, CO 80045, United States; Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO 80045, United States.
| | - Steven L Moulton
- University of Colorado School of Medicine, Aurora, CO 80045, United States; Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO 80045, United States.
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20
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Chandrasekaran A. Pancreatico duodenectomy for pediatric combined duodenal, pancreatic and biliary trauma. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408615580203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreaticoduodenal trauma in children is uncommon but carries high morbidity and mortality rates, especially when the diagnosis is delayed. A case of combined pancreatico duodenal and bile duct injury following blunt abdominal trauma is described which presented two days after injury. It highlights the extremes of surgical procedures that may be needed in massive blunt trauma.
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Abstract
Trauma is the leading cause of death in children of all ages. The most common site of injury in pediatric patients is the head followed by the extremities and the abdomen. Though less than 10% of admissions to the hospital are secondary to intra-abdominal injuries, mortality related to these injuries is not insignificant. Pancreatic and duodenal trauma occurs in 3 to 12% of the patients with abdominal injuries and can be associated with significant morbidity. The management of pancreatic and duodenal trauma in children is based mostly on adult data, but there is an increasing volume of research on the subject.
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Affiliation(s)
- Aaron Lesher
- Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Regan Williams
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States
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22
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Lim YJ, Nam SH, Kim SJ. Large intraluminal ileal hematoma presenting as small bowel obstruction in a child. IRANIAN JOURNAL OF RADIOLOGY 2015; 12:e8212. [PMID: 25901264 PMCID: PMC4393502 DOI: 10.5812/iranjradiol.8212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 02/20/2013] [Accepted: 06/26/2013] [Indexed: 11/29/2022]
Abstract
Intraluminal small bowel hematoma has been rarely reported in children, as a rare cause of small bowel obstruction. We present a case of an intraluminal ileal hematoma presenting as small bowel obstruction in a child. Computed Tomography (CT) indicated a large intraluminal hyperdense lesion in the distal ileum as the cause of small bowel obstruction. Abdominal ultrasonography (US) showed an echogenic mass-like lesion with multiple septa in the distal ileum. Small bowel obstruction due to a complicated cystic mass was provisionally diagnosed. Histopathologic examination of the resected mass suggested a submucosal ileal hematoma. Although intraluminal small bowel hematoma is rare in children, it can present as an intraluminal cystic mass and should be considered as a rare cause of small bowel obstruction. The US and CT findings of submucosal ileal hematoma could be useful for the diagnosis of such cases in the future.
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Affiliation(s)
- Yun Jung Lim
- Department of Radiology, Haeundae Paik Hostpital, Inje University, Inje, South Korea
- Corresponding author: Yun Jung Lim, Department of Radiology, Haeundae Paik Hostpital, Inje University, Jwa-dong, Haeundae-gu, Busan, Inje, South Korea. Tel: +82-517970363, Fax: +82-517970379, E-mail:
| | - So Hyun Nam
- Department of Pediatric Surgery, Haeundae Paik Hostpital, Inje University, Inje, South Korea
| | - Seon Jeong Kim
- Department of Radiology, Haeundae Paik Hostpital, Inje University, Inje, South Korea
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Sheybani EF, Gonzalez-Araiza G, Kousari YM, Hulett RL, Menias CO. Pediatric nonaccidental abdominal trauma: what the radiologist should know. Radiographics 2015; 34:139-53. [PMID: 24428287 DOI: 10.1148/rg.341135013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abdominal injury in nonaccidental trauma (NAT) is an increasingly recognized cause of hospitalization in abused children. Abdominal injuries in NAT are often severe and have high rates of surgical intervention. Certain imaging findings in the pediatric abdomen, notably bowel perforation and pancreatic injury, should alert the radiologist to possible abuse and incite close interrogation concerning the reported mechanism of injury. Close inspection of the imaging study is warranted to detect additional injury sites because these injuries rarely occur in isolation. When abdominal injury is suspected in known or speculated NAT, computed tomography (CT) of the abdomen and pelvis with intravenous contrast material is recommended for diagnostic and forensic evaluation. Although the rate of bowel injury is disproportionately high in NAT, solid organs, including the liver, pancreas, and spleen, are most often injured. Adrenal and renal trauma is less frequent in NAT and is generally seen with multiple other injuries. Hypoperfusion complex is a constellation of abdominal CT findings that indicates current or impending decompensated shock and is most often due to severe neurologic impairment in NAT. Although abdominal injuries in NAT are relatively uncommon, knowledge of injury patterns and their imaging appearances is important for patient care and protection.
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Affiliation(s)
- Elizabeth F Sheybani
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo
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24
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Kernbach-Wighton G, Banaschak S, Madea B, Pollak S, Thierauf-Emberger A, Tsokos M, Geserick G, Schmeling A, Saternus KS. Klinische Rechtsmedizin und forensisch-klinische Untersuchungen. Rechtsmedizin (Berl) 2015. [DOI: 10.1007/978-3-662-43500-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Goddard L, Bowkett B, Kenwright D. Elasticity of abdominal wall vessels in children: clinical implications in child abuse. ANZ J Surg 2014; 84:755-7. [PMID: 24995516 DOI: 10.1111/ans.12715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abdominal trauma secondary to non-accidental injury is associated with high rates of morbidity and mortality. It has been noted that children who have suffered abusive abdominal injuries often lack abdominal wall bruising. We hypothesize that children have highly elastic vessels that stretch instead of rupturing when the abdomen is punched. Our study investigates the degree of elasticity in abdominal wall vessels in young children. METHODS Twenty children aged less than 5 years undergoing routine hernia repair or orchidopexy were included in our study. Subcutaneous vessels were identified during the procedures. The vessels were measured at resting length and when stretched to maximum length prior to rupture. Samples of the vessels were then collected for histological examination. RESULTS On average, we were able to stretch the vessels to 3.4 times their resting length without rupture. Histology revealed that the vessel walls contained a high amount of elastin. CONCLUSION We have demonstrated a high degree of elasticity in the abdominal wall vessels of young children. This may help to explain why children do not bruise when hit in the abdomen. Our findings have potential implications for both clinical practitioners and paediatric surgeons involved in child abuse cases.
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Affiliation(s)
- Lucy Goddard
- Department of Paediatric Surgery, Wellington Children's Hospital, Wellington, New Zealand
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Abstract
Neurosurgeons are mainly concerned with child abuse in cases of severe cranio-cerebral trauma. Aim of the present paper is to highlight the clinical picture and symptoms in cases of child abuse and our multidisciplinary approach to reveal a solid diagnosis. The detection of child abuse requires a high index of suspicion, especially in cases of subtle injuries. Besides reporting to the appropriate agencies primary goals are to terminate suspected abuse and to prevent further harm to the child. All this requires a confirmed diagnosis.
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Affiliation(s)
- B Madea
- Institute of Legal Medicine, University of Bonn, Bonn, Germany
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Ueda N, Shimotake T, Ohama K. Duodenal perforation associated with norovirus and rotavirus gastroenteritis. Clin Case Rep 2013; 1:47-9. [PMID: 25356210 PMCID: PMC4184747 DOI: 10.1002/ccr3.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/25/2013] [Accepted: 09/10/2013] [Indexed: 11/12/2022] Open
Abstract
Key Clinical Message Norovirus (NoV) and rotavirus (RV) gastroenteritis are usually self-limiting. However, few pediatric cases of bowel perforation and no duodenal perforation with NoV gastroenteritis were reported. We describe two children with duodenal perforation due to NoV or RV gastroenteritis. Suspicion for this association enables prompt intervention, preventing lethal outcomes of these common infections.
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Affiliation(s)
- Norishi Ueda
- Department of Pediatrics, Public Central Hospital of Matto Ishikawa Ishikawa, Japan
| | - Takashi Shimotake
- Department of Pediatric Surgery, Ishikawa Prefecture Central Hospital Ishikawa, Japan
| | - Kazunori Ohama
- Department of Pediatric Surgery, Ishikawa Prefecture Central Hospital Ishikawa, Japan ; Department of Pediatric Surgery, Public Central Hospital of Matto Ishikawa Ishikawa, Japan
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28
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Hemorrhagic pyloroduodenal duplication cyst misdiagnosed as child abuse. J Pediatr 2013; 163:1224-1224.e1. [PMID: 23684110 DOI: 10.1016/j.jpeds.2013.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/03/2013] [Indexed: 11/23/2022]
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Maguire SA, Upadhyaya M, Evans A, Mann MK, Haroon MM, Tempest V, Lumb RC, Kemp AM. A systematic review of abusive visceral injuries in childhood--their range and recognition. CHILD ABUSE & NEGLECT 2013; 37:430-445. [PMID: 23306146 DOI: 10.1016/j.chiabu.2012.10.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 10/28/2012] [Accepted: 10/31/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children. METHODS We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome. RESULTS Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated. CONCLUSIONS Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.
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Affiliation(s)
- S A Maguire
- Child Health Department, School of Medicine, Cardiff University, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
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Gutierrez IM, Mooney DP. Operative blunt duodenal injury in children: a multi-institutional review. J Pediatr Surg 2012; 47:1833-6. [PMID: 23084193 DOI: 10.1016/j.jpedsurg.2012.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 04/09/2012] [Accepted: 04/17/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIM Operative blunt duodenal injury in children is rare. The purpose of this analysis is to describe the clinical presentation, current management, and outcome of children with operative blunt duodenal injury. METHODS The American Pediatric Surgical Association Trauma Committee solicited data from its members on children with blunt intestinal injuries identified at autopsy or operation from January 2002 through August 2006. RESULTS Fifty-four children from 16 hospitals with operative blunt duodenal injuries were identified: 0.67 patients per hospital per year. The most common mechanisms of injury were motor vehicle crashes (35%), bicycle crashes (22%), and nonaccidental trauma (20%). Forty-nine patients (90%) had positive physical examination findings on initial presentation, including peritonitis in 18 patients (33%). Twenty-five computed tomographic (CT) scans performed demonstrated free fluid, and 13 (52%), free air. Eleven CT scans used enteral contrast, and only 2 (18%) showed extravasation. Fifty-two patients (96%) survived to operation. The overall complication rate was 42%. CONCLUSION Operative blunt duodenal injury occurs less than once per year in the typical pediatric trauma center. Most of the patients have pertinent physical examination findings on arrival. Computed tomographic scans with enteral contrast do not seem to be helpful in diagnosis of duodenal injuries. Postoperative complications are frequent, but most children survive.
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Affiliation(s)
- Ivan M Gutierrez
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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32
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Abstract
Injuries to the duodenum pose a diagnostic and therapeutic challenge to the surgeon. Due to the intra- and extra-peritoneal location of the duodenum, the presentation can be overt or occult, and delay in diagnosis is associated with an increased mortality rate. A range of interventions have been described and this article reviews the relevant literature, highlights the salient points and suggests a treatment algorithm.
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Affiliation(s)
- Mansoor A Khan
- Specialist Registrar, General Surgery, Doncaster Royal Infirmary, Doncaster, UK
| | - Jeff Garner
- Consultant Colorectal Surgeon, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Clive Kelty
- Consultant General and Upper GI Surgeon, Doncaster Royal Infirmary, Doncaster, UK
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34
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Abstract
Intra-abdominal injuries from impacts are the second most common cause of death in battered children. However, it may be difficult to distinguish between accidental abdominal injury and abuse, especially in the absence of other clinical findings. Published reports are also limited about the diagnosis of abuse in children with intra-abdominal injury. We report a case with jejunal perforation, multiple soft tissue injuries, and occipital fracture secondary to child abuse who was initially admitted to our hospital with complaint of fever, cough, and vomiting. An exploratory laparotomy revealed perforation of the jejunum, and an end-to-end anastomosis was performed. The patient was evaluated by the hospital's child protective team to implement appropriate diagnostic and child-protective interventions, and the child was discharged home in 10 days.
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35
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Lethal visceral traumatic injuries secondary to child abuse: A case of practical application of autopsy, radiological and microscopic studies. Forensic Sci Int 2011; 206:e62-6. [DOI: 10.1016/j.forsciint.2010.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Revised: 07/18/2010] [Accepted: 08/31/2010] [Indexed: 12/26/2022]
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Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD. Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use? Pediatr Radiol 2011; 41:92-8. [PMID: 20936274 DOI: 10.1007/s00247-010-1847-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 08/19/2010] [Accepted: 09/01/2010] [Indexed: 12/01/2022]
Abstract
BACKGROUND Incomplete history and concern for occult injury in suspected child abuse occasionally results in CT screenings of the abdomen and pelvis. At our institution, we noted that these exams were infrequently positive. OBJECTIVE To identify clinical or laboratory criteria that may predict intra-abdominal injury and guide the use of abdominal and pelvic CT in this population. MATERIALS AND METHODS This retrospective review involved 68 children older than 36 months who had a CT of the abdomen/pelvis for suspected abuse. CT results and patient charts were reviewed for physical exam and historical and laboratory variables. RESULTS CTs were positive in 16% of patients (11/68). Hypoactive/absent bowel sounds (P = 0.01, specificity = 94.7%) and AST and ALT values greater than twice normal (P = 0.004 and P = 0.003 respectively, NPV = 93.6%) were significantly associated with positive CTs. Multiple abnormal physical exam or laboratory findings were also significantly associated with positive CTs (P = 0.03 and P = 0.002 respectively, specificity = 91.3% and NPV = 93.6% respectively). CONCLUSION CTs of the abdomen and pelvis are infrequently positive in cases of suspected abuse. To reduce radiation exposure, CTs should only be ordered if there are findings indicating that they may be positive. In our population, these findings include absent/hypoactive bowel sounds, LFTs greater than twice normal and ≥2 abnormal labs or physical exam findings.
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Affiliation(s)
- Andrew T Trout
- Department of Radiology, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, MI 48109-5030, USA.
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Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K, Shapiro R. Utility of hepatic transaminases to recognize abuse in children. Pediatrics 2009; 124:509-16. [PMID: 19620197 DOI: 10.1542/peds.2008-2348] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. PATIENTS AND METHODS This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken. RESULTS Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4-4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. CONCLUSIONS In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.
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Affiliation(s)
- Daniel Lindberg
- Department of Emergency Medicine, Brigham and Women'sHospital, Boston, Massachusetts 02115, USA.
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39
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Abstract
The diagnosis of abuse in a child with occult abdominal injuries is difficult. Not many patients with nonaccidental trauma present with a clear history of the injury. The absence of a reliable history in patients with nonaccidental trauma makes determination of an exact mechanism difficult. In most cases, patients present to the emergency department with inaccurate or misleading histories; some give no history of trauma, which may delay recognition of serious abdominal injuries. In addition, the child may have other injuries, such as neurologic or musculoskeletal, which divert attention from occult abdominal injuries. Pancreatic and duodenal injuries are considered specific for abuse. We report a child with pancreatic injury without an appropriate history of trauma, determined to be caused by nonaccidental trauma.
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Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol 2008; 43:72-82. [PMID: 18053830 DOI: 10.1053/j.ro.2007.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Sarah D Bixby
- Department of Radiology, Children's Hospital Boston, Boston, Massachusetts 02115,
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41
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Choi YJ, Kim SM, Sim EJ, Cho DJ, Kim DH, Min KS, Yoo KY. A Clinical Study of Child Abuse. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.5.436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yoon Jin Choi
- Department of Pediatrics, College of Medicine, Hallym University, Korea
| | - Shin Mi Kim
- Department of Pediatrics, College of Medicine, Hallym University, Korea
| | - Eun Jung Sim
- Department of Pediatrics, College of Medicine, Hallym University, Korea
| | - Do Jun Cho
- Department of Pediatrics, College of Medicine, Hallym University, Korea
| | - Dug Ha Kim
- Department of Pediatrics, College of Medicine, Hallym University, Korea
| | - Ki Sik Min
- Department of Pediatrics, College of Medicine, Hallym University, Korea
| | - Ki Yang Yoo
- Department of Pediatrics, College of Medicine, Hallym University, Korea
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Bechtel K, Moss RL, Leventhal JM, Spiro D, Abo A. Duodenal hematoma after upper endoscopy and biopsy in a 4-year-old girl. Pediatr Emerg Care 2006; 22:653-4. [PMID: 16983252 DOI: 10.1097/01.pec.0000235840.52072.0c] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a 4-year-old girl who developed a duodenal hematoma after upper endoscopy and biopsy. Although rare, duodenal hematoma formation can occur after upper endoscopy and biopsy in otherwise healthy children. A young child presenting with a duodenal hematoma in the absence of a clear mechanism of either previous gastrointestinal procedures or injury to the abdomen should have an extensive evaluation to exclude child abuse. A thorough evaluation for other medical causes, such as a coagulopathy, should be performed simultaneously.
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Abstract
The visible evidence of child physical abuse most often is minimal or nonexistent, and the children at greatest risk of becoming victims are those too young to verbalize the history. As pediatric clinicians, we must be able to recognize potential sequelae of abuse and the high-risk situations that lead to physical abuse; we also must acknowledge that victims of child physical abuse often have injuries at multiple locations and in multiple organ systems. As a routine part of pediatric practice, healthcare providers, through anticipatory guidance, try to maximize the child's safety in the home environment. With this goal in mind, healthcare providers must consider the possibility of physical abuse when faced with a child with a traumatic injury. While it is important to identify these inflicted injuries, our ultimate goal is to prevent their occurrence in the first place.
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Affiliation(s)
- Sara Thompson
- Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
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45
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Abstract
OBJECTIVE The purpose of this review is to review how pediatric trauma may predispose children to sepsis. DESIGN The information discussed in this report is derived from a recent literature review of pediatric trauma and related topics and discussion at an international consensus conference on pediatric sepsis. MEASUREMENTS AND MAIN RESULTS There is a paucity of evidence on sepsis-related complications in pediatric trauma patients. Severe traumatic brain injury is a leading predisposing factor for sepsis complications. Excluding burn trauma, traumatically injured children without severe head injury rarely succumb to overwhelming sepsis. CONCLUSIONS Patients with multiple traumatic injuries are frequently admitted to the intensive care unit, and because head injury is the most common ailment, unconscious patients with a combination of injuries that include head injury will regularly require mechanical ventilation and central venous access and are at risk for life-threatening nosocomial infections. Outside of pulmonary contusions, organ-specific causes of infection are infrequent.
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Affiliation(s)
- Jeffrey S Upperman
- Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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