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Child Abuse Case 19


A 2.5-year-old boy presents with a history of vomiting at home for the last 24 hours. He was previously healthy except for frequent bruises to his face, chest and abdomen. He recently fell down two steps at the front of his home. His physical exam reveals a tender, distended abdomen. There are bruises on his anterior chest, lower back and forehead, but the abdominal skin is not bruised. His abdominal radiograph reveals the finding demonstrated here:


Case 19


What is the most likely cause of this finding?

  1. Abdominal trauma secondary to the stairway fall.
  2. A bowel perforation due to inflicted trauma.
  3. Pneumoperitoneum due to a perforated appendicitis.
  4. An intussusception associated with Henoch-Schonlein Purpura.

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The answer is B.

Abdominal injury due to child abuse is frequently missed due to lack of external signs of trauma. Extraluminal air can be seen in this radiograph as dark (air) in spaces just below the diaphragm. In a report by Gaines, bowel perforation due to child abuse was the second most frequent mechanism of injury, following motor vehicle accidents. In this study, isolated duodenal injury was an unusual finding and other injuries were present. A search for other injuries (liver contusions or lacerations, pancreatic trauma, rib fractures, head injuries, etc.) must be undertaken. Consider using the "What to Do When Physical Abuse is Suspected" checklist (see Resource below) when abdominal injury is identified in a child who has no history of trauma. In children younger than 3 years of age with no history of a motor vehicle accident and signs of duodenal trauma or perforation, child abuse should be suspected.

Direct trauma to the abdomen can cause a duodenal hematoma or perforation due to the anatomy of the gastrointestinal tract. A direct blow to the epigastrium, such as a punch, kick or stomp, results in injury by tearing the duodenal-jejunal junction at the site of attachment of the ligament of Treitz. The ligament is a band of smooth muscle that extends from this junction to the crus of the diaphragm and functions as a suspensory ligament. The ligament essentially holds the bowel in place so that the force of the trauma causes a tear or contusion. Bowel perforation requires immediate referral for surgical exploration and repair. An abdominal CT scan will help document injuries to other organs, fluid collections and bowel ischemia.

Stairway falls rarely cause intra-abdominal injuries (Huntimer). It is likely that the history of a stairway fall was used by the offender to provide a way to divert attention from the real incident while also enabling the child to get medical attention.

A perforated appendix can present with bowel perforation, but the history should include other factors that lead to a diagnosis of appendicitis. Similarly, Henoch-Schonlein Purpura (HSP) may cause bowel edema and intussusception that results in a perforation, but the history would more likely include episodes of intermittent, crampy abdominal pain. The purpuric lesions of HSP should be differentiated from bruises on clinical examination and generally occur on the lower extremities.

Spontaneous bowel perforation has been described in the literature, but it is unclear whether these reported cases represent missed cases of child abuse.


References
Gaines BA, Shultz BS, Morrison K, Ford HR. Duodenal injuries in children: Beware of child abuse. J of Pediatric Surgery. 2004;39:600-602.

Huntimer CM, Muret-Wagstaff S, Leland NL. Can falls on stairs result in small intestine perforations? Pediatrics. 2000;106:301-305.


Resource
What to do before you call a child abuse expert when physical abuse is suspected in a child under 2 years old (PDF)


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