Abdominal Trauma
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Abdominal trauma is an injury to the
abdomen The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
. Signs and symptoms include
abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...
, tenderness, rigidity, and
bruising A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur clo ...
of the external abdomen. Complications may include
blood loss Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...
and
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
. Diagnosis may involve
ultrasonography Medical ultrasound includes diagnostic techniques (mainly imaging) using ultrasound, as well as therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal body structures such as tendons, muscles, joints, ...
,
computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
, and peritoneal lavage, and treatment may involve surgery. It is divided into two types
blunt Blunt may refer to: * Blunt (surname), a surname (and list of people with the name) * Blunt (cigar), a term used in the cigar industry to designate blunt-tipped, usually factory-rolled cigars * Blunt (cannabis), a slang term used in cannabis cult ...
or penetrating and may involve damage to the abdominal
organs In a multicellular organism, an organ is a collection of tissues joined in a structural unit to serve a common function. In the hierarchy of life, an organ lies between tissue and an organ system. Tissues are formed from same type cells to a ...
. Injury to the lower
chest The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main di ...
may cause splenic or liver injuries.


Signs and symptoms

Signs and symptoms are not seen in early days and after some days initial pain is seen. People injured in motor vehicle collisions may present with a "
seat belt A seat belt, also known as a safety belt or spelled seatbelt, is a vehicle safety device designed to secure the driver or a passenger of a vehicle against harmful movement that may result during a collision or a sudden stop. A seat belt reduce ...
sign", bruising on the abdomen along the site of the lap portion of the safety belt; this sign is associated with a high rate of injury to the abdominal organs. Seatbelts may also cause abrasions and hematomas; up to 30 percent of people with such signs have associated internal injuries. Early indications of abdominal trauma include
nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...
,
vomiting Vomiting (also known as emesis, puking and throwing up) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting can be the result of ailments like food poisoning, gastroenteritis, pre ...
,
blood in the urine Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. "Gross hematuria" occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable with ...
, and
fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...
. The injury may present with
abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...
, tenderness, distension, or rigidity to the touch, and bowel sounds may be diminished or absent.
Abdominal guarding The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
is a tensing of the abdominal wall muscles to guard inflamed organs within the abdomen.
Pneumoperitoneum Pneumoperitoneum is pneumatosis (abnormal presence of air or other gas) in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal organ, generally from a perforated peptic ulcer, alt ...
, air or gas in the
abdominal cavity The abdominal cavity is a large body cavity in humans and many other animals that contain Organ (anatomy), organs. It is a part of the abdominopelvic cavity. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roo ...
, may be an indication of rupture of a hollow organ. In penetrating injuries, an evisceration (protrusion of internal organs out of a wound) may be present.Chih, p.343 Injuries associated with intra-abdominal trauma include
rib fracture A rib fracture is a break in a rib bone. This typically results in chest pain that is worse with inspiration. Bruising may occur at the site of the break. When several ribs are broken in several places a flail chest results. Potential complicat ...
s,
vertebral fracture A spinal fracture, also called a vertebral fracture or a broken back, is a fracture affecting the vertebrae of the spinal column. Most types of spinal fracture confer a significant risk of spinal cord injury. After the immediate trauma, there is ...
s, pelvic fractures, and injuries to the
abdominal wall In anatomy, the abdominal wall represents the boundaries of the abdominal cavity. The abdominal wall is split into the anterolateral and posterior walls. There is a common set of layers covering and forming all the walls: the deepest being the vi ...
.Hemmila, p. 231


Causes

Motor vehicle collisions are a common source of blunt abdominal trauma. Seat belts reduce the incidence of injuries such as
head injury A head injury is any injury that results in trauma to the skull or brain. The terms ''traumatic brain injury'' and ''head injury'' are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of inju ...
and chest injury, but present a threat to such abdominal organs as the
pancreas The pancreas (plural pancreases, or pancreata) is an Organ (anatomy), organ of the Digestion, digestive system and endocrine system of vertebrates. In humans, it is located in the abdominal cavity, abdomen behind the stomach and functions as a ...
and the
intestines The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascular system. ...
, which may be displaced or compressed against the
spinal column The spinal column, also known as the vertebral column, spine or backbone, is the core part of the axial skeleton in vertebrates. The vertebral column is the defining and eponymous characteristic of the vertebrate. The spinal column is a segmen ...
. Children are especially vulnerable to abdominal injury from seat belts, because they have softer abdominal regions and seat belts were not designed to fit them. In children,
bicycle A bicycle, also called a pedal cycle, bike, push-bike or cycle, is a human-powered transport, human-powered or motorized bicycle, motor-assisted, bicycle pedal, pedal-driven, single-track vehicle, with two bicycle wheel, wheels attached to a ...
mishaps are also a common cause of abdominal injury, especially when the abdomen is struck by the handlebars. Sports injuries can affect abdominal organs such as the spleen and kidneys. Falls and sports are also frequent mechanisms of abdominal injury in children. Abdominal injury may result from
child abuse Child abuse (also called child endangerment or child maltreatment) is physical abuse, physical, child sexual abuse, sexual, emotional and/or psychological abuse, psychological maltreatment or Child neglect, neglect of a child, especially by a p ...
and is the second leading cause of child abuse-related death, after
traumatic brain injury A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumati ...
. Gunshot wounds, which are higher energy than stab wounds, are usually more damaging than the latter.Chih, pp. 346–348 Gunshot wounds that penetrate the
peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...
result in significant damage to major intra-abdominal structures in some 90 percent of cases.


Pathophysiology

Abdominal trauma can be life-threatening because abdominal organs, especially those in the
retroperitoneal space The retroperitoneal space (retroperitoneum) is the spatium, anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum ...
, can bleed profusely, and the space can hold a great deal of blood. Solid abdominal organs, such as the
liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...
and
kidney In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organ (anatomy), organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and rig ...
s, bleed profusely when cut or torn, as do major blood vessels such as the
aorta The aorta ( ; : aortas or aortae) is the main and largest artery in the human body, originating from the Ventricle (heart), left ventricle of the heart, branching upwards immediately after, and extending down to the abdomen, where it splits at ...
and
vena cava In anatomy, the ''venae cavae'' (; ''vena cava'' ; ) are two large veins ( great vessels) that return deoxygenated blood from the body into the heart. In humans they are the superior vena cava and the inferior vena cava, and both empty into t ...
. Hollow organs such as the
stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...
, while not as likely to result in shock from profuse bleeding, present a serious risk of infection, especially if such an injury is not treated promptly. Gastrointestinal organs such as the bowel can spill their contents into the abdominal cavity.
Hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, ...
and systemic infection are the main causes of deaths that result from abdominal trauma. One or more of the intra-abdominal organs may be injured in abdominal trauma. The characteristics of the injury are determined in part by which organ or organs are injured.


Liver

The
liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...
, the most vulnerable abdominal organ to all forms of injury because of its size and location (in the upper right quadrant of the abdomen), is injured in about five percent of all people admitted to a hospital for trauma. Liver injuries present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity. The liver may be
lacerated A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying diseas ...
or contused, and a hematoma may develop. It may leak
bile Bile (from Latin ''bilis''), also known as gall, is a yellow-green/misty green fluid produced by the liver of most vertebrates that aids the digestion of lipids in the small intestine. In humans, bile is primarily composed of water, is pro ...
, usually without serious consequences. If severely injured, the liver may cause
exsanguination Exsanguination is the loss of blood from the circulatory system of a vertebrate, usually leading to death. The word comes from the Latin 'sanguis', meaning blood, and the prefix 'ex-', meaning 'out of'. Exsanguination has long been used as a met ...
(bleeding to death), requiring emergency surgery to stop the bleeding.


Spleen

Spleen is the most common cause of massive bleeding in blunt abdominal trauma to a solid organ. Spleen is the most commonly injured organ. A laceration of the spleen may be associated with hematoma. Because of the spleen's ability to bleed profusely, a ruptured spleen can be life-threatening, resulting in
shock Shock may refer to: Common uses Healthcare * Acute stress reaction, also known as psychological or mental shock ** Shell shock, soldiers' reaction to battle trauma * Circulatory shock, a medical emergency ** Cardiogenic shock, resulting from ...
. However, unlike the liver, penetrating trauma to the spleen, pancreas and kidneys do not present as much of an immediate threat of shock unless they lacerate a major blood vessel supplying the organs, such as the
renal artery The renal arteries are paired arteries that supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle. The renal arteries carry a large portion of total blood flow to the kidneys. Up to ...
. Fractures of the left lower ribs are associated with spleen lacerations in 20 percent of cases.


Pancreas

The pancreas may be injured in abdominal trauma, for example by laceration or contusion. Pancreatic injuries, most commonly caused by bicycle accidents (especially by impact with the handlebars) in children and vehicular accidents in adults, usually occur in isolation in children and accompanied by other injuries in adults. Indications that the pancreas is injured include enlargement and the presence of fluid around the pancreas.


Kidneys

The kidneys may also be injured; they are somewhat but not completely protected by the ribs. Kidney lacerations and contusions may also occur. Kidney injury, a common finding in children with blunt abdominal trauma, may be associated with bloody urine. Kidney lacerations may be associated with urinoma or leakage of urine into the abdomen. A ''shattered kidney'' is one with multiple lacerations and an associated fragmentation of the kidney tissue.


Bowel

The
small intestine The small intestine or small bowel is an organ (anatomy), organ in the human gastrointestinal tract, gastrointestinal tract where most of the #Absorption, absorption of nutrients from food takes place. It lies between the stomach and large intes ...
takes up a large part of the abdomen and is likely to be damaged in penetrating injury. The bowel may be perforated. Gas within the abdominal cavity seen on CT is understood to be a diagnostic sign of bowel perforation; however intra-abdominal air can also be caused by
pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and dyspnea, shortness of breath. In a minority of cases, a one-way valve is ...
(air in the
pleural cavity The pleural cavity, or pleural space (or sometimes intrapleural space), is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enabl ...
outside the
lung The lungs are the primary Organ (biology), organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the Vertebral column, backbone on either side of the heart. Their ...
s that has escaped from the
respiratory system The respiratory system (also respiratory apparatus, ventilatory system) is a biological system consisting of specific organs and structures used for gas exchange in animals and plants. The anatomy and physiology that make this happen varies grea ...
) or
pneumomediastinum Pneumomediastinum (from Greek Greek may refer to: Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group *Greek language, a branch of the Indo-European language family **Proto-Greek language, the assume ...
(air in the
mediastinum The mediastinum (from ;: mediastina) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is a region that contains vital organs and structures within the thorax, mainly the heart and its vessels, the eso ...
, the center of the chest cavity). The injury may not be detected on CT. Bowel injury may be associated with complications such as infection,
abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...
,
bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...
, and the formation of a
fistula In anatomy, a fistula (: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") is an abnormal connection (i.e. tube) joining two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other h ...
. Bowel perforation requires surgery.


Diagnosis

Ten percent of people with
polytrauma Polytrauma and multiple trauma are medical terms describing the condition of a person who has been subjected to multiple traumatic injuries, such as a serious head injury in addition to a serious burn. The term is defined via an Injury Severity S ...
who had no signs of abdominal injury did have evidence of such injuries using radiological imaging. Diagnostic techniques used include
CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
ning,
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
, and
X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
. X-ray can help determine the path of a penetrating object and locate any foreign matter left in the wound, but may not be helpful in blunt trauma. Diagnostic
laparoscopy Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medli ...
or exploratory
laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ...
may also be performed if other diagnostic methods do not yield conclusive results.


Ultrasound

Ultrasound can detect fluid such as blood or gastrointestinal contents in the abdominal cavity, and it is a noninvasive procedure and relatively safe. CT scanning is the preferred technique for people who are not at immediate risk of shock, but since ultrasound can be performed right in an emergency room, the latter is recommended for people who are not stable enough to move to CT scanning. A normal ultrasound does not rule out all injuries.


CT

People with abdominal trauma frequently need CT scans for other trauma (for example, head or chest CT); in these cases abdominal CT can be performed at the same time without wasting time in patient care. CT is able to detect 76% of hollow viscous injuries so people who have negative scans are often observed and rechecked if they deteriorate. However, CT has been demonstrated to be useful in screening people with certain forms of abdominal trauma in order to avoid unnecessary laparotomies, which can significantly increase the cost and length of hospitalizations. A meta-analysis of CT use in penetrating abdominal traumas demonstrated sensitivity, specificity and accuracy >= 95%, with a PPV of 85% and an NPV of 98%.


Peritoneal lavage

Diagnostic peritoneal lavage is a controversial technique but can be used to detect injury to abdominal organs: a catheter is placed in the
peritoneal cavity The peritoneal cavity is a potential space located between the two layers of the peritoneum—the parietal peritoneum, the serous membrane that lines the abdominal wall, and visceral peritoneum, which surrounds the internal organs. While situated ...
, and if fluid is present, it is aspirated and examined for blood or evidence of organ rupture. If this does not reveal evidence of injury, sterile saline is infused into the cavity and evacuated and examined for blood or other material. While peritoneal lavage is an accurate way to test for bleeding, it carries a risk of injuring the abdominal organs, may be difficult to perform, and may lead to unnecessary surgery; thus it has largely been replaced by ultrasound in Europe and North America.


Classification

Abdominal trauma is divided into blunt and penetrating types. While penetrating abdominal trauma (PAT) is usually diagnosed based on clinical signs, diagnosis of blunt abdominal trauma is more likely to be delayed or altogether missed because clinical signs are less obvious. Blunt injuries predominate in rural areas, while penetrating ones are more frequent in urban settings. Penetrating trauma is further subdivided into
stab wounds A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including br ...
and
gunshot wound A gunshot wound (GSW) is a penetrating injury caused by a projectile (e.g. a bullet) shot from a gun (typically a firearm). Damage may include bleeding, bone fractures, organ damage, wound infection, and loss of the ability to move part of ...
s, which require different methods of treatment.


Treatment

Abdominal trauma requires urgent medical attention and sometimes requires hospitalization. The initial treatment involves stabilizing the person enough to ensure adequate airway, breathing, and circulation, and identifying other injuries. Surgery may be needed to repair injured organs. Surgical exploration may be necessary for people with penetrating injuries and signs of
peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...
or shock.
Laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ...
is often performed in blunt abdominal trauma, and is urgently required if an abdominal injury causes a large, potentially deadly bleed. The main goal is to stop any sources of bleeding before moving onto any definitive find and repair any injuries that are found. Due to the time sensitive nature, this procedure also emphasizes expedience in terms of gaining access and controlling the bleeding, thus favoring a long midline incision. Intra-abdominal injuries are also frequently successfully treated nonoperatively as there is little benefit shown if there is no known active bleeding or potential for infection. The use of CT scanning allows care providers to use less surgery because they can identify injuries that can be managed conservatively and rule out other injuries that would need surgery. Depending on the injuries, a person may or may not need
intensive care Intensive care medicine, usually called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. It includes p ...
. For injuries that penetrate the
peritoneal cavity The peritoneal cavity is a potential space located between the two layers of the peritoneum—the parietal peritoneum, the serous membrane that lines the abdominal wall, and visceral peritoneum, which surrounds the internal organs. While situated ...
(penetrating abdominal trauma),
prophylactic Preventive healthcare, or prophylaxis, is the application of healthcare measures to prevent diseases.Hugh R. Leavell and E. Gurney Clark as "the science and art of preventing disease, prolonging life, and promoting physical and mental health a ...
(preventative) antibiotics are often administered with the goal of reducing the risk of
sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...
and septic complications, including
septicaemia Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...
,
abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...
es in the abdomen, and wound infections. The effectiveness of the use of antibiotics prophylactically for penetrating abdominal trauma has not been well studied and there is no strong evidence to support one particular antibiotic type or dose over another. The length of time that these antibiotics should be used for is also not clear.


Prognosis

If abdominal injury is not diagnosed promptly, a worse outcome is associated. Delayed treatment is associated with an especially high
morbidity A disease is a particular abnormal condition that adversely affects the structure or function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical conditions that are asso ...
and mortality if perforation of the gastrointestinal tract is involved.


Epidemiology

In the United Kingdom, abdominal trauma due to road traffic accidents and assaults are most common. This situation is reversed in South Africa and United States where firearms related trauma are the most common. Most deaths resulting from abdominal trauma are preventable; abdominal trauma is one of the most common causes of preventable, trauma-related deaths.


References


Bibliography

* *


External links

{{Authority control Injuries of abdomen, lower back, lumbar spine and pelvis Medical emergencies Trauma types