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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 177-179

Blunt abdominal trauma presenting as an isolated intraperitoneal bladder rupture: A diagnostic and therapeutic dilemma


1 Department of Paediatric surgery, M.M.Medical College, Solan, Himachal Pradesh, India
2 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
3 Department of Anaesthesiology and Intensive Care, SGRD Medical College, Amritsar, Punjab, India
4 Department of Anaesthesiology and Intensive Care, DMC, Ludhiana, Punjab, India

Date of Web Publication9-Aug-2017

Correspondence Address:
Sukhminder Jit Singh Bajwa
House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_93_16

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  Abstract 


Bladder rupture is very rare clinical finding in pediatric age group. This should be suspected in any child who does not pass urine, develops abdominal distension, pain, and tenderness in the lower abdomen after sustaining blunt trauma to the abdomen. Delay in presentation and diagnosis further increases the morbidity and mortality. Isolated bladder rupture is a rare consequence of blunt trauma in the absence of pelvic fracture. We are reporting a rare case with an isolated bladder rupture in which no any other associated injury was present. The patient had presented 24 h after sustaining the injury with clinical features of anuria and peritonitis. Emergency surgery was undertaken to save the child.

Keywords: Blunt trauma abdomen, intraperitoneal bladder rupture, isolated bladder rupture


How to cite this article:
Gupta M, Bajwa SJ, Singh AP, Khanna M, Khanna L. Blunt abdominal trauma presenting as an isolated intraperitoneal bladder rupture: A diagnostic and therapeutic dilemma. Int J Health Allied Sci 2017;6:177-9

How to cite this URL:
Gupta M, Bajwa SJ, Singh AP, Khanna M, Khanna L. Blunt abdominal trauma presenting as an isolated intraperitoneal bladder rupture: A diagnostic and therapeutic dilemma. Int J Health Allied Sci [serial online] 2017 [cited 2019 Jun 27];6:177-9. Available from: http://www.ijhas.in/text.asp?2017/6/3/177/212599




  Introduction Top


The incidence and pattern of blunt abdominal trauma have not changed over the last decade in spite of the adoption of various safety measures. Solid organ injury like liver and spleen can easily be established by sonography, but the diagnosis of hollow visceral injury presents a significant challenge to the attending emergency physician. Among the hollow visceral injury, small bowel is the most commonly involved.[1] However, bladder rupture is an uncommon injury in pediatric trauma population.[2] Chances of injury to full bladder due to trauma are higher as it causes sudden increase of intravesicular pressure and the weakest point of the bladder, the dome, ruptures most commonly.[3] Differentiation between intra- and extra-peritoneal rupture is important as extraperitoneal rupture can be managed conservatively, but intraperitoneal rupture needs urgent surgery and repair of the bladder.[2],[4] Delay in presentation can cause electrolyte disturbances, derangement of renal functions, and leukocytosis. Delay in presentation and management increases the incidence of morbidity and mortality. The late presentation could be due to masking of symptomatology of primary laceration or development of secondary rupture at hematoma of the bladder wall.[5] Therefore, bladder injury should be suspected and investigated during blunt abdominal trauma in every small child. The common clinical presentation of such injury in children can be distension of abdomen due to urinary ascites, lower abdominal pain, inability to void and perineal ecchymosis.[4] We are reporting a case of 3-year-old child who had nonmotor vehicular accident injury and presented as distension of abdomen and anuria 24 h after injury. The case can be described as rare and unique as the child had isolated bladder injury without any evidence of pelvic fracture or any other solid organ injury.[4]


  Case Report Top


A 3-year-old boy was brought to the emergency room of our hospital by his parents with a history of blunt trauma to abdomen sustained 24 h back. As narrated by his parents, whereas playing near his residence, he got hit by a collapsing wall and subsequently got buried under the collapsed wall. He was taken out immediately, but within few moments he had one episode of vomiting, pain abdomen, and gradually distension abdomen while his level of consciousness was fine. The child did not pass any urine after the injury for 24 h before the presentation. On examination, the child appeared pale and acutely ill, with a heart rate of 150/min and respiratory rate was 40 breaths/min. On admission, noninvasive blood pressure was 104/70 mm Hg and oxygen saturation on pulse oximetry was 94% in room air. On examination, there was guarding and rigidity in the abdomen. The child was administered intravenous fluids, antibiotics and was catheterized as a part of initial resuscitation. However, only 15 ml of blood-tinged fluid from catheter was observed in urine reservoir bag tubing after 2 h despite the fluid challenge. Ultrasonography (USG) was done which showed thick walled urinary bladder with a discontinuity in the region of dome suggestive of peritoneal rupture of the urinary bladder. The hemogram and biochemical profile of the child revealed values of hemoglobin as 8.6 g/dL, total leukocyte count - 10,300/cumm, blood urea 95 mg/dL, serum creatinine - 1.9 mg/dL, serum sodium - 138 mEq/L, serum potassium - 5.4 mEq/L, and serum chloride was 102 mEq/L.

An immediate plan for surgical intervention was made considering the seriousness of clinical and radiological findings. After the child was induced with general anesthesia and intubated with an appropriate sized endotracheal tube, surgical intervention was undertaken. During surgery, it was found that urinary bladder was ruptured intraperitoneally and there was flip-flap like discontinuity in the region of dome [Figure 1]. The bladder was repaired in two layers, and abdominal warm saline peritoneal lavage was done followed by insertion of drain [Figure 2]. No anaesthetic complication was encountered, and peri-operatively the hemodynamic course remained stable. The abdominal drain was removed on the 5th postoperative day. However, the patient developed an omental prolapse at the drain site which was repositioned. Overall, the rest of recovery period was uneventful and urinary catheter was removed on the 10th postoperative day and the patient was discharged home satisfactorily.
Figure 1: Bladder rupture like flip flap

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Figure 2: Bladder being repaired

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  Discussion Top


The most common cause of blunt abdominal injury is motor vehicle accident in children. Since the introduction of the seat belt in vehicles, there has been a significant reduction in mortality due to a head injury, but an increased incidence of mesenteric and small bowel injury can be seen.[1] Among other common causes of injury to children include child abuse. Injury to kidneys or development of urinary symptoms is an uncommon manifestation of child abuse and the majority of times these injuries are likely to go unrecognized.[6] Urological injuries are most common in the lower part of the urinary tract and urinary bladder.[7] However, isolated bladder injuries are rare and are most commonly associated with injuries to other major abdominal organs or pelvic injuries. These injuries in a child can present as abdominal pain, emesis, constipation, multiple ecchymoses, and abdominal distension. Urological manifestations can occur in the form of hematuria or bladder distension which occasionally can be a part of the acute renal failure.

The bladder can rupture intraperitoneally or extraperitoneally. It is important to differentiate between both as treatment of extraperitoneal bladder rupture is usually conservative. Extraperitoneal rupture is commonly associated with pelvic fractures. Bladder in small children is mostly intraabdominal and is less protected by pubic symphysis. If any blunt injury occurs to the abdomen with full bladder, the bladder is most likely to rupture intraperitoneally. The most plausible explanation for such an isolated injury is that due to the sudden rise of intravesicular pressure, the bladder can rupture at its weakest point which is the dome of the bladder. There can be extravasations of urine and blood into peritoneal cavity which can lead to resorption of urine that can cause electrolyte imbalance, acidosis, and uremia.

However, a delayed presentation of bladder rupture can occur due to possible masking of primary laceration symptoms or due to the development of secondary rupture at the site of a hematoma in the bladder wall.[5] Delayed presentation and diagnosis may be associated with laboratory abnormalities such as metabolic derangements and leukocytosis which can substantially increase the incidence of mortality. Intraperitoneal bladder rupture is most commonly associated with other associated injuries such as a pelvic fracture. Isolated bladder rupture after accidental trauma is very rare which encouraged us to share this case report on the journal platform.[4]

Although the investigation of choice is computed tomography (CT) abdomen, in our case we did not wait for CT scanning as the child was sick with aggressive clinical features of peritonitis. Therefore, the decision of surgery was taken considering the clinical emergency and convincing radiological findings of bladder rupture on USG only. During research for scientific evidence for such cases, it was found that some authors preferred retrograde cystograms also if there is any diagnostic dilemma even with radiological findings. Open surgical repair has been the standard treatment for intraperitoneal bladder rupture. Osman et al. had justified nonoperative treatment also.[8] However if there is prolonged urinary leakage from the peritoneal drain or lack of improvement on conservative measures, surgery is advised on an emergency basis which is commonly done by open repair. This is also assume significance as the patient may have associated injuries to other organs which could be missed during initial investigations. Recently, laparoscopic repair of intraperitoneal bladder injuries has been preferred provided that the patient is stable, but the plan should be changed to open surgical intervention on development of any hemodynamic instability or surgical complication.[9]


  Conclusions Top


Bladder rupture must be suspected in any child if there is abdominal pain, distension, urinary retention, hematuria, electrolyte abnormalities including uremia, elevated chloride after blunt abdominal trauma in a child. Delayed bladder injury presentation is possible and high index of suspicion is needed for timely treatment and better prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abbas SM, Upadhyay V. Hollow viscus injury in children: Starship hospital experience. World J Emerg Surg 2007;2:14.  Back to cited text no. 1
[PUBMED]    
2.
Lautz T, Leonhardt D, Rowell E, Reynolds M. Intraperitoneal bladder rupture as an isolated manifestation of nonaccidental trauma in a child. Pediatr Emerg Care 2009;25:260-2.  Back to cited text no. 2
[PUBMED]    
3.
Kessler DO, Francis DL, Esernio-Jenssen D. Bladder rupture after minor accidental trauma: Case reports and a review of the literature. Pediatr Emerg Care 2010;26:43-5.  Back to cited text no. 3
[PUBMED]    
4.
Alhamzawi HH, Abdelrahman HM, Abdelrahman KM, El-Menyar A, Al-Thani H, Latifi R. Delayed presentation of traumatic intraperitoneal rupture of urinary bladder. Case Rep Urol 2012;2012:430746.  Back to cited text no. 4
[PUBMED]    
5.
Brown D, Magill HL, Black TL. Delayed presentation of traumatic intraperitoneal bladder rupture. Pediatr Radiol 1986;16:252-3.  Back to cited text no. 5
[PUBMED]    
6.
Sirotnak AP. Intraperitoneal bladder rupture: An uncommon manifestation of child abuse. Clin Pediatr (Phila) 1994;33:695-6.  Back to cited text no. 6
[PUBMED]    
7.
Deibert CM, Glassberg KI, Spencer BA. Repair of pediatric bladder rupture improves survival: Results from the National Trauma Data Bank. J Pediatr Surg 2012;47:1677-81.  Back to cited text no. 7
[PUBMED]    
8.
Osman Y, El-Tabey N, Mohsen T, El-Sherbiny M. Nonoperative treatment of isolated posttraumatic intraperitoneal bladder rupture in children-is it justified? J Urol 2005;173:955-7.  Back to cited text no. 8
[PUBMED]    
9.
Kim B, Roberts M. Laparoscopic repair of traumatic intraperitoneal bladder rupture: Case report and review of the literature. Can Urol Assoc J 2012;6:E270-3.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]



 

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