A 18 year male patient presented to the emergency department following fall from tree of height of about 3 meters after are cent meal .There was no history of loss of consciousness or vomiting but only abdominal pain and mild distension. Hence patient did not present to the hospital. Patient was brought to hospital12hours later with fever, abdominal distension and abdominal pain. On examination the patient was conscious and coherent. Pulse was 120/min, bounding and blood pressure was 100/70 mm of Hg with raised temperature and tachypnea. There was now tenderness and guarding of upper abdomen. There were no other injuries. CECT abdomen show pneumo peritoneum with fluid in abdomen and dilated stomach (Figure 1). Laboratory parameters were within normal limit. The patient was resuscitated and taken up for exploratory laparotomy. Exploratory laparotomy showed dark coloured fluid about 1 litre and a 6 cm long, full thickness oblique gastric rupture on the lesser curve of the body of the stomach, 2 cms below the gastro esopha geal junction (Figure 2). There were no associated intra-abdominal injuries (Figures 3 and 4). After peritoneal lavage, due to massive oblique gastric rupture and peritoneal contamination, total gastrectomy and oesophago jeunostomy was done. Post operatively, patient developed severe lung consolidation and went in for septic shock and expired on POD 4. Blunt traumatic gastric ruptures are uncommon with an incidence of between 0.02 to 1.7% [1,2] and are usually associated with other solid visceral injuries where the most common organ of involvement is the spleen [3,4]. Associated injury have been reported in 83% to 93% [5] of cases. Such Injuries to the stomach are associated with the highest mortality of all hollow viscus injuries [6]. Road traffic accident is the most common cause of gastric rupture accounting around 75% [7]. Other causes are fall from a height, seat-belt injuries, and even vigorous resuscitation [2]. The relative infrequency of gastric perforationis due to protection by the thoracic cage, the mobility of the stomach and thick, viable vascular gastric wall [3].

Figure 1: CT showing free fluid abdomen with thickened, dilated stomach (with black arrow) and mininmal pneumoperitoeum (blue arrow).

Figure 2: Intra operative picture showing the large rupture along the lesser curve of about 7 cm (arrow) with stomach being held along the greater curvature.

Figure 3: Transverse stapler being applied at the distal end to resect the stoma.

Figure 4: Linear Stapler applied proximally to resect the stomach and do oesophageojeunal anastomosis.

Classically, gastric perforations due to BAT [Blunt Abdominal Trauma] have been attributed to 3 mechanisms:

1) External compression to a distended fed stomach causes a sudden raise in intra gastric pressure leading to rupture at weakest point.

2) Rapid deceleration causing tear of organs and vascular pedicles to tear at points of attachment.

3) Crush between the anterior abdominal wall and the vertebral column or posterior thoracic cage

Most of the perforations are solitary [5] and the common location for gastric perforations the anterior wall (40%) followed by the greater curvature (23%), lesser curvature (15%) and posterior wall (15%). However, the greater curvature is the site most often affected in the paediatric age group [8].

Morbidity and mortality correlate with increased time to operative intervention [6] and the overall reported mortality ranges from 0–66% [4,5]. The majority of complications due to rupture are septic in nature with in trabdominal abscesses being most common [9]. It is to be noted that the fed patient with distended stomach has a higher gastric pH that predisposesto a greater bacterial load with more infective complications. Free intra peritoneal air on plain abdomen and chest x-ray films is seen only in 16-66% of the cases [10,11].

Shock on presentation is seen in 20% of cases [12]. Patient must be taken for emergency surgery when suspicious features are seen on imaging or when there is shock, aspiration of dark coloured fluid on peritoneal lavage or paracentesis. This is diagnostic and must be followed by exploration [8]. The definite features of perforation on CT scan include, pneumoperitoneum, unexplained in traperitoneal fluid and other features like bowel wall thickening, and mesenteric fat stranding [9]. However, it is not100% sensitive and may miss a perforation in about 13%.

Adequate peritoneal lavage, debridement and repair with a 2-layer closure followed by peritoneal drainage is the treatment of choice for blunt gastric rupture. The high morbidity and mortality associated with blunt trauma rupture of stomach are related to diagnostic delay, associated injuries, and complications [10]. Having a high index of suspicion, making an early diagnosis, performing adequate debridement and repair, and aggressively treating any complications are keys to survival [7,10].

Although gastric rupture in blunt trauma usually occurs as a single lesion in the stomach, surgeons should be aware of possible multiple ruptures. Preoperative CT study is effective for a prompt diagnosis and treatment. Early diagnosis and prompt treatment of the rupture is essential for the patient’s survival.