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The development of fever or worsening peritonitis on serial physical
examinations should alert the examining physician to the possibility of bowel
perforation.
Plain radiographs of the abdomen demonstrate free intra-abdominal air in only
30% to 50% of cases. Similarly, pneumoperitoneum or leakage of gastrointestinal
contrast is only rarely seen on the CT scan. Most perforations or transections of
bowel are found during laparotomy or laparoscopy which the surgeon has chosen
to perform because of advancing peritonitis or unexplained persistent fever.
Management depends on the site and extent of structural injury.
A significant percentage (up to 25%) of hollow visceral injuries may not be
apparent on the initial CT scan of a child with blunt injury. Therefore, evaluating
the mechanism of injury should lead to a high index of suspicion for this type of
injury. A significant lap belt sign is a harbinger of possible bowel injury.
Similarly, unexplained free fluid (e.g., not associated with a solid visceral injury)
in the abdomen on CT scan should be very carefully evaluated and consideration
should be given for laparoscopy or laparotomy.

Late Presentations of Intra-Abdominal Trauma
Some children with abdominal trauma do not have evidence of intra-abdominal
pathology on initial evaluation but may return days or weeks later with abdominal
distention and/or pain, persistent emesis, or hematochezia. In particular, three
injuries are characterized by late presentations: (i) pancreatic pseudocyst
(previously discussed), (ii) duodenal hematoma, and (iii) hematobilia.
Intramural duodenal hematoma is an uncommon injury that results from a
direct blow to the epigastrium (blunt force delivered by a small-diameter
instrument such as a broom handle or the toe of a boot) or from rapid deceleration
(e.g., in the lap belt syndrome) and may cause partial or complete gastric outlet
obstruction. Bleeding into the wall of the duodenum causes compression and
resultant symptoms of intestinal obstruction, including pain, bilious vomiting, and
gastric distention.
Diagnosis is made by ultrasonography, contrast upper gastrointestinal study, or

a CT scan revealing the “coiled-spring sign” or a soft tissue mass in the bowel
wall. Injury of the pancreas must be suspected when duodenal hematoma is
considered. Nonoperative management includes nasogastric decompression and
parenteral nutrition for up to 3 weeks.
Rupture of the gallbladder is rare and is almost always associated with severe
blunt trauma to the liver. It will almost always be accompanied by severe
peritonitis. Likewise, hematobilia is associated with hepatic trauma and is a result
of pressure necrosis from an intrahepatic hematoma or direct injury to the biliary