Chronic trans-rectal impalement with jejunal and duodenal perforations in a young child: a case report

Rectal penetrating trauma is a rare but potentially life-threatening injury in children. Diagnosis is challenging, especially when external signs are minimal or when clinical manifestations appear in a delayed fashion. We describe a 46-month-old Vietnamese girl with a complex clinical history, initially managed for a presumed drowning event and severe aspiration pneumonia 4 months prior to admission. Persistent symptoms unresponsive to treatment prompted further imaging, which revealed a large intra-abdominal foreign body. Exploratory surgery, converted from an initial diagnostic laparoscopy to laparotomy, identified a 16 × 1 cm wooden branch. The object had perforated the posterolateral rectal wall, ascended through the retroperitoneum, perforated the jejunum 50 cm distal to the ligament of Treitz, and penetrated the D2 segment of the duodenum, resulting in a localized retroperitoneal abscess. Management included removal of the foreign body, primary repair of the rectal, jejunal, and duodenal perforations, peritoneal lavage, placement of a subhepatic drain, and creation of a diverting double-barrel sigmoid colostomy. Postoperative recovery was uneventful. This report describes an exceptionally rare case of chronic (4-month) trans-rectal impalement injury with high-level, multi-visceral gastrointestinal perforations. The preceding “drowning” history significantly obscured the diagnosis. This case highlights the importance of maintaining a high index of suspicion for occult penetrating trauma in children with complex and non-specific presentations, and underscores the need for thorough operative exploration.