Case 72

A 4 year-old boy who was previously healthy was brought to the emergency department by the police. They were called by a neighbour who heard the boy screaming and crying. The boy disclosed that his mother’s boyfriend held him against the wall and punched him with his fist twice on his abdomen. He complains of abdominal pain. When you examine him, you note abdominal tenderness and multiple healed patterned marks on his abdomen (Image 72) and on his arms and legs. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig72.jpg"/>

What does the image show?

What tests and further imaging are important to evaluate this patient?

164

The image shows the left flank area and abdomen of the child. He has multiple patterned loop marks that have healed with hyperpigmentation. Loop marks result from being whipped with a cord or a belt and indicate this child has been physically abused. Although we cannot date when bruises originally occurred, these loop marks have healed so they must have occurred sometime before he was brought for medical care. ¹ Children who disclose physical abuse need a detailed physical examination to further evaluate their presentation as well as document previous instances of abuse.

Due to the child’s disclosure of being punched in the abdomen, he needs to be further evaluated for internal injuries. Blood was drawn for a complete blood count as well as liver and pancreatic enzymes. His liver enzymes were elevated: alanine aminotransferase (ALT) 866 U/L, aspartate transaminase (AST) 478 U/L. The normal range for ALT is reported between 7 and 56 units per litre and for AST between 10 and 40 units per litre. It is recommended that children with transaminases levels >80 U/L should undergo definitive testing for abdominal injury in cases where physical abuse is suspected as in this child. ² A CT scan of his abdomen showed a small liver laceration with mild periportal oedema as well as retroperitoneal fluid collection between the aorta and inferior vena cava. Due to the fluid collection an upper gastrointestinal series with barium as a contrast was done which showed thickened duodenal folds, which may be due to oedema secondary to the patient’s history of trauma. An exploratory laparotomy was performed which confirmed the contusion of the liver. It also revealed contusions of the transverse colon and duodenum. This case highlights the importance of a full evaluation of children disclosing physical abuse. Children need to be screened for abdominal trauma initially with liver enzymes. Abdominal trauma is the second most common cause of death from abuse and needs to be recognized in a timely manner. However, children may have significant abdominal trauma with mild symptoms as in this case and with few or no physical findings on exam.