Gastric Rupture

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• Answer to the Clinical Challenges and Images in GI Question: Image 2: Gastric Rupture
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Question: A 24-year-old man was brought by ambulance to our emergency department after a motorcycle accident. On arrival, although the patient was alert and vital signs were stable, he complained of increasing diffuse abdominal pain. Although plain radiographs of the chest and pelvis and abdominal ultrasound seemed normal, physical inspection revealed muscular rigidity on palpation. The patient also presented with signs of peritonitis; laboratory results were within normal limits. A whole-body scan using contrast-enhanced conventional axial computed tomography (CT; Figure A) as well as a coronal CT (Figure B) were performed.

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Given these observations, what is the most likely diagnosis?

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Answer to the Clinical Challenges and Images in GI Question: Image 2: Gastric Rupture 

Gastric rupture is rarely caused by blunt abdominal trauma, with occurrence ranging between 0.02% and 1.7%.¹ Although diagnosis of gastric rupture in the present case was based on clinical examination, preoperative diagnosis is generally difficult because physical findings frequently reveal abdominal pain and peritoneal signs, which are not specific to gastric rupture. Further, gastric rupture diagnosis by radiographic evaluation is unreliable owing to free air being absent on x-ray films in >50% of cases.² Although abdominal axial CT scanning facilitates visualization of intra-abdominal free air,³ coronal CT should be considered for suspected gastric rupture because of the easy observation of leakage of gastric contents. Compared with the clear representation of gastric rupture using coronal CT (Figure B, white arrow), no clear representation was obtained using axial CT in the present case (Figure A). These observations suggest diagnosis of gastric rupture cannot be reliably achieved using axial CT. Coronal CT, however, may facilitate the early and precise diagnosis of gastric rupture, leading to an early and appropriate treatment, as well as a decreased period of peritoneal contamination, sepsis, and shock.

Laparotomy revealed superficial splenic laceration and gastric rupture, with a large, 10-cm gastric lesion extending along the greater curvature of the posterior gastric wall (Figure C). Splenic laceration was performed with pre-jet and 1-0 Vicryl sutures, and gastric rupture was repaired primarily by 2-layer closure using 3-0 Vicryl and 3-0 silk simple suturing. The patient showed rapid improvement with no complications, and was discharged on day 17 posttrauma.

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References 

1. Rodriguez-Hermosa JI, Roig J, Sirvent JM, et al. Gastric perforations from abdominal trauma. Dig Surg. 2008;25:109–116
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2. Nanji Sulaiman A, Mock C. Gastric rupture resulting from blunt abdominal trauma and requiring gastric resection. J Trauma. 1999;47:410–412
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3. Shinkawa H, Yasuhara H, Naka S, et al. Characteristic features of abdominal organ injuries associated with gastric rupture in blunt abdominal trauma. Am J Surg. 2004;187:384–397
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