Delayed presentation of herniated ileal perforation after blunt abdominal injury

Summary Blunt abdominal injuries are not uncommon; however, ileal perforation caused by blunt trauma, especially when associated with an inguinal hernia, is a very rare event, and a difficult diagnosis. We present the case of a 63-year-old male who had sustained a blunt abdominal injury on his left inguinal hernia in a bicycle versus motorcycle accident. Computed tomography (CT) scans on arrival at hospital showed the left inguinal hernia with partial protrusion of the small intestine, without categorical inflammatory changes of the mesenteric tissue or intraperitoneal fluid. During observation, he sustained intermittent lower abdominal pain. About 8 hours later, hypotension and fever ensued. The repeated CT scans showed adjacent bowel edema with free air, and a hernia sac, in the left lower quadrant of the abdomen. Emergency laparotomy revealed ileal perforation. Segmental resection with end-to-end anastomosis was performed. The patient made an uneventful recovery and was discharged 2 weeks later. Although the CT scan has become the gold standard in evaluating abdominal trauma, delayed perforation of the intestine with blunt injuries may escape early detection. Serial physical examinations with a high index of suspicion are mandatory in susceptible patients to avoid time-related complications. The imaging findings from a single examination should not be depended upon solely.