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Analysis of deaths from traffic accidents in a Brazilian capital

Muhammad Usman Shah1*, Moarij Amer Qazi1, Mobasser Mahmood1, Ahsin Manzoor Bhatti2
  1. MBBS Student, Army Medical College, National University of Sciences and Technology, Pakistan
  2. MBBS, FCPS (Surgery), FRCS (Ireland), FRCS (Vascular UK), General and Vascular Surgeon,Combined Military Hospital, Rawalpindi Pakistan
Corresponding Author: Muhammad Usman Shah, House 516, Street 5, Sector C4, Phase 5, Hayatabad, Peshawar, Pakistan Phone number: +92-346-9187704 , Email: [email protected], [email protected]
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Abstract

 Introduction: Over the past 60 years, the urbanization process has intensified around the world. It is estimated that each year 1.2 million people die due to traffic accidents (TA) in the world. Annually, about 37.000 people die and other 180.000 are hospitalized due to TA in Brazil. The frequency of deaths in Brazilian States and Capitals and how they occur, comply with different standards and specific locations. Thus, it becomes essential to know their distribution according to variables such as sex, age and injury type to guide the creation of interventional measures to begin to settle the TA and their victims.

Objective: To assess the deaths from traffic accidents occurred in the city of Maceio in the period of 2001 to 2010.

Method: It is a descritive study, which used secondary data from the Database of the Mortality Information System (SIM), available on the Department of Health of Maceió (SMS) in July 2011. The variables studied were deaths by type of accident, sex and age. Data were analyzed using EpiInfo version 3.5.3.

Results: In the period of 2001-2010, occurred 53,186 deaths, which 1,369 (2.57%) were due to traffic accidents. The type of fatal accident that occurred most frequently was involving pedestrians (48.88%), followed by accidents classified as ''other' transport accidents” (37.61%). Death in men is more often presented with 1122 (81.95%) cases. The deaths were more prevalent among persons of 15 to 49 years, with 924 cases (67.49%), followed by the deaths of those 50 years or more (23.59%).

Conclusion: This study showed that the deaths from traffic accidents (TA) in the city of Maceio, as well as in Brazil and elsewhere in the world are alarming and could be prevented. Thus, there is the need to create interventional measures, which must include improvements on the structural conditions of the roads, with more rigid enforcement of the laws of the traffic, and also realizing programs of education in the transit in a more frequent and proficient way

Keywords

Gastrointestinal bleed, jejunal diverticula, lower gastrointestinal tract.

Introduction

Lower Gastro-Intestinal Bleeding (LGIB) is bleeding occurring distal to the ligament of Trietz. It may present as hematochezia ranging from minor to severe, the latter being occasionally lethal. Almost 20% of all severe gastro-intestinal bleeding may appear as cases of LGIB.1
Common causes of the condition include Inflammatory Bowel Disease, haemorrhoids, anal fissures, neoplastic conditions and coagulopathies.2 A rare cause includes superior mesenteric artery (SMA) dissection resulting in thrombosis and bowel ischemia. It may occur as a complication of aortic dissection3. Uncommonly, small bowel diverticula may also present with a similar picture. However, they are usually asymptomatic and difficult to treat and diagnose.4

Case Report

A 40 year old man presented with severe, sudden onset of breathlessness, fatigue and bloody stools for the past 10 days. Bleeding was fresh, profuse and constant with a frequency of 5 times per day. It was not associated with pain. He had undergone aortic valve replacement last year and had been on warfarin therapy since then.
Examination revealed blood pressure of 100/60 mmHg, pulse 90/min, Temperature 99.2° F, with marked pallor, raised JVP and systolic murmurs. Complete blood count revealed haemoglobin of 7.1 mg/dl, total red blood cell count of 2.65x 1012/L and total leukocyte count of 19.9x 109 /L. Neutrophils were 83%, serum urea was 11.5 mmol/L and creatinine was 142μmol/L. Coagulation profile was deranged. His blood pH and lactate levels were normal. He was stabilized with transfused blood and Fresh Frozen Plasma (FFPs). Bedside echo showed more than 5 cm dilatation of ascending and descending aorta. Upper GI endoscopy revealed an ulcer in the proximal portion of duodenum with the histopathology report showing a benign nature. Colonoscopy showed presence of fresh blood in the gut. CT angiography was arranged which showed type “A” aortic dissection with extension into superior mesenteric artery.
A provisional diagnosis of aorto-enteric fistula or ischaemic gut secondary to thrombosis due to extension of dissection into superior mesenteric artery was made. Ct angiography showed the same results. Exploratory laparotomy was done with the view to either resect gangrenous bowel or carry out an aorto-mesenteric bypass in case of occluded SMA. However, it showed normal superior mesenteric artery and its dependant bowel area, although multiple actively bleeding jejunal diverticula were found on the mesenteric border. They were resected and end-to-end anastomosis was done.
The patient was followed up after the procedure in the post operation ward. His bleeding had stopped and his blood stats were improving.

Discussion & Conclusion

Lower Gastro-intestinal Bleeding is an important cause of severe lethal bleeding and death in adults. Aortic dissection is a rare cause of this condition. While it usually presents with chest and abdominal pains, it may also manifest as lethal LGIB.3 This may occur as a result of extension into Superior Mesenteric Artery (SMA) with the subsequent thrombosis causing severe bowel ischemia in the tissue distribution of the vessel. Consequently, severe LGIB may occur resulting in signs of shock.5 This was the suspected cause of LGIB in our patient. He had previous history and confirmed diagnosis of aortic dissection type “A” extending to SMA thus raising the likelihood of bleeding secondary to ischaemic gut. However, another rare cause, jejunal diverticula must be kept in the differential diagnosis of such patients. They are particularly difficult to diagnose both as a result of lack of routine bowel endoscopies and the low yield of the procedure 6, leaving laparotomy to be the diagnostic and therapeutic tool in such cases.7,8,9 The latter procedure was carried out to determine the site of the ischaemic gut in our patient. However, jejunal diverticula were found to be the most probable cause of LGIB in the absence of any ischaemic gut.
This case report therefore highlights the importance of rare causes of LGIB in the adult population including those mentioned in the above case discussion. It also goes to show that a relatively benign condition such as jejunal diverticula may mimic the clinical presentation of a more sinister cause such as SMA thrombosis and bowel ischaemic, the latter associated with greater morbidity and mortality. Nonetheless, a high index of suspicion for these is a must to effectively manage and save the patient’s life.

Abbreviations used

LGIB: Lower Gastrointestinal bleed
SMA: Superior mesenteric artery

Authors' Contributions

Muhammad Usman Shah: Patient data collection, literature review and writing of the manuscript.
Moarij Amer Qazi: Patient data collection and literature review of the article.
Mobasser Mahmood: literature review and writing of the manuscript.
Ahsin Manzoor Bhatti: Selected the case report and presented the basic theme of the article, supervised and corrected it.
Conflict of interest
None

References

  1. Kagir B, Katz J. Lower Gastrointestinal Bleeding; Background. Medscape https://emedicine.medscape.com/article/188478-overview; Published June 1, 2011. Accessed June 18, 2012.

  2. Kagir B, Katz J. Lower Gastrointestinal Bleeding; Etiology. Medscape https://emedicine.medscape.com/article/188478-overview#aw2aab6b2b4aa; Published June 1, 2011. Accessed June 18, 2012.

  3. Nath HP, Jaques PF, Soto B, Keller FS, Ceballos R. Aortic dissection masquerading as gastrointestinal disease. CardiovascInterventRadiol. 1986;9(1):37-41.

  4. Brasoveanu V, David L, Buga I, Popescu I. A rare cause of lower digestive hemorrhage--jejunal diverticulosis Chirurgia (Bucur). 2005 Jul-Aug;100(4):369-72.

  5. Sharifi M, Sorkin R, Lakier J, Chaitra S. Thoracic aortic thrombosis as a cause of bowel ischemia. A case report.Angiology. 1994 Nov;45(11):973-7.

  6. Brasoveanu V, David L, Buga I, Popescu I. A rare cause of lower digestive hemorrhage--jejunal diverticulosis Chirurgia (Bucur). 2005 Jul-Aug;100(4):369-72.

  7. Yamaner S, Akyüz M, Buğra D. Massive lower gastro-intestinal bleeding due to small bowel diverticula. A report of two cases.ActaChir Belg. 2006 Jul-Aug;106(4):427-9.

  8. Tan KK, Liu JZ, Ho CK. Emergency surgery for jejunal diverticulosis: our experience and review of literature. ANZ J Surg. 2011 May;81(5):358-61.

  9. Ríos A, Montoya MJ, Rodríguez JM, Parrilla P. Acute lower gastrointestinal hemorrhage originating in the small intestine. Rev EspEnferm Dig. 2006 Mar;98(3):196-203.

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