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From question on page 927

A 100 mm segment of the proximal jejunum had an irregular outline, with areas of constriction due to scarring. Histology (fig 2) showed fibrosis of the subserosa, and interruption and replacement of the muscularis propria by fibrosis. The submucosa and epithelium were normal.

The diagnosis was seat belt injury.

Two proposed mechanisms explain the occurrence of small bowel obstruction after blunt abdominal injury: direct and indirect. The direct theory postulates that viscera get compressed between the abdominal wall and spinal column under the shearing force of the fastened seat belt. In the healing process, fibrosis causes constrictions that may result in partial or complete obstruction.

In the indirect mechanism, viscera suffer from ischaemia secondary to mesenteric injury, with involvement of the superior and inferior mesenteric arteries. As Miss M’s mesenteric structures were normal on laparotomy, the scarring she sustained seems to have been the result of direct trauma to the gut. The duodenum and jejunum are particularly vulnerable in the seat belt syndrome because of their proximity to the vertebral column, as well as their relation to the fastened seat belt.

The affected segment was excised and this patient was discharged, totally recovered, nine days after surgery.

Figure 2

 Histology of the proximal jejunum. The mucosa and submucosa are normal, whereas there is interruption of the muscularis propria, with fibrous scarring (between the arrows). Van Gieson stain, original magnification ×100.

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