A 23-year-old, male truck driver presented to the emergency room (ER) with 1 h history of diffuse abdominal pain, which developed suddenly after jumping from the driver's door of his Indian jumbo truck, which is approximately about 2 m high from the ground. He landed on the ground on his feet. He denied any blunt trauma to his abdomen. He did not report any gastrointestinal symptoms such as nausea or vomiting. He doesn't have medical comorbidities such as peptic ulcer disease.
On examination, he was conscious, afebrile, and not pale. Pulse rate was 110 beats per minute (bpm) and blood pressure was 110/60 mmHg. Abdominal examination revealed distended abdomen with diffuse guarding and rigidity. The bowel sounds were sluggish. Digital rectal examination was unremarkable. There were no visible external injuries such as bruises in the skin, and fractured bones. The neurological examination of both upper and lower limbs was unremarkable.
Complete blood count (CBC) was within the normal range:leukocytes of 2700/mm3, neutrophil:79%, hemoglobin:11 gm%, and platelet count of 367,000/mm3. Serum amylase was within the normal range of 40 U/L. Focused assessment with sonography in trauma (FAST) revealed minimal free fluid in the pelvis. A postero-anterior (PA) chest X ray revealed air under the right hemi-diaphragm (Figure 1).
Possibility of bowel perforation, and the need for an emergency exploratory laparotomy to look for the cause of pneumoperitoneum and appropriate treatment was explained, and a written informed consent obtained. Exploratory laparotomy with midline incision under general anesthesia was performed. On exploring the abdominal cavity, there was minimal hemoperitoneum with bile-stained fluid. There was a full thickness perforation involving two-third of the circumference of the proximal jejunum near the ligament of Treitz (Figure 2). There were no other bowel injuries or other pathologies suggestive of malignancies or intestinal tuberculosis noted during the exploration. Peritoneal lavage with copious amount of normal saline, was followed by primary repair of the injury. The perforated segment of the jejunum was repaired in two layers using 3-0 vicryl. The first layer was sutured continuously, and the second layer was sutured with Lembert suture. An 18 French drain tube was placed in close proximity to the repaired jejunal segment and the abdomen was closed in the standard steps.
He was initiated on oral liquids on the third postoperative day. He tolerated oral intake, and gradually converted to normal diets. The drainage was removed on the second postoperative day. He made an uneventful recovery in the postoperative period, and was discharged home on the seventh postoperative day. On follow-up at the 30th postoperative day, his wound was healed, and abdomen was soft with normal bowel habits.