Small bowel perforation and fatal peritonitis following a fall in a 21-month-old child
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CASE REPORT
Small bowel perforation and fatal peritonitis following a fall in a 21-month-old child Andrew M. Davison Æ Edgar J. Lazda
Accepted: 7 April 2008 / Published online: 14 May 2008 Humana Press 2008
Abstract The authors report a case of fatal peritonitis due to small bowel perforation in a 21-month-old female child. Necropsy excluded natural disease and a thorough Coronial investigation concluded that an accidental fall onto a ‘‘doorstop’’ caused the bowel injury. The investigative findings are presented; the discussion address issues of diagnosis and causation/mechanism of injury. Keywords Small bowel perforation Fall Furniture Child Forensic Pediatrics
Introduction Trauma is the leading cause of death between 1 and 18 years of age; the majority of cases are due to blunt trauma and the abdomen is the second most common site of injury [1]. It is difficult to assess the incidence of small bowel perforation in children following an episode of ‘‘significant’’ blunt abdominal trauma but it is probably ‘‘relatively rare’’ i.e. less than 5% [2–4]. The majority of such cases are due to vehicle- or bicycle-related accidents or assault, therefore, the possibility of physical abuse must be considered [1–9]. However, it should be remembered that falls and ‘‘unusual’’ incidents occasionally may be responsible [2, 6, 9–13].
A. M. Davison (&) Wales Institute of Forensic Medicine, Cardiff University College of Medicine, Cardiff CF14 4XN, UK e-mail: [email protected] E. J. Lazda Department of Pathology, Cardiff University College of Medicine, Cardiff CF14 4XN, UK
Case report Circumstances of death A 21-month-old female became ill, i.e., vomiting and not eating, two days prior to death. She was taken to the family’s General Practitioner the following day; a ‘‘red throat’’ was noted and antibiotics were prescribed; her abdomen was not examined. She continued to vomit and the next morning her father phoned for an ambulance. Resuscitation was attempted at home and by ambulance and hospital staff. Life was pronounced extinct approximately half an hour after admission to hospital. A Consultant Pediatrician spoke to the parents and elicited a history of a possible fall onto a doorstop two days previously. There was no significant medical history. There were no retinal hemorrhages. An external examination revealed three ‘‘fresh’’ bruises (1.0 cm 9 0.6 cm; 2.5 cm 9 1.5 cm; 1.5 cm 9 1.0 cm) over the mid lumbar spine and small ‘‘fresh’’ bruises over the lower edge of the ribcage bilaterally but no bruising on the front of the abdomen. The Pediatrician was of the opinion that the ribcage bruising was due to resuscitation, the bruising on the lower back was ‘‘due to an accident’’ and he stated to the Coroner: ‘‘I have not been suspicious about non-accidental injury.’’ Indeed, the clinical suspicion was of gastroenteritis, volvulus, or intussusception. It was concluded that there were no suspicious circumstances. The Coroner was informed and a postmortem examination was ordered. A radiographic skeletal survey to ex
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