Closed Abdominal Injuries

Classification of Abdominal trauma Penetrating trauma

solid viscera injury Blunt trauma hollow viscera injury

Injuries from blunt trauma are more common and more difficult to assess

Mechanism of closed abdominal injury Deceleration forces from motor vehicle accidents

or falls may tear organs from their points of fixation

e.g. liver, bladder, gutA steering wheel or other solid object striking the

abdomen may disrupt any of the organs that cross the vertebral column

e.g. pancreas, duodenum, vena cava

Characteristic features of different organ injuries Parenchymal organ injury hollow organ injury liver, spleen, kidney stomach, intestine, gallbladder

internal hemorrhage acute peritonitis

pulses BP abdominal tenderness

abdomen soft rigidity

tenderness not clearly rebound tenderness

rebound tenderness obvious diminishing of liver dullness

presence of shifting dullness

Diagnosis—whether there is viscus damage

Repeated frequent examination is essential

Get the history of injuries

symptoms:abdominal pain, vomiting, nausea,

blood stained stool, hematuria,

management after injury

Physical examination

BP, pulses, temperature, abdominal tenderness,

rigidity, rebound tenderness, diminishing of liver

dullness, presence of shifting dullness and alter-

nation of bowel sound, P.R examination

Laboratory findings

intraabdominal bleeding: RBC Hb

WBC pancreatic injury: amylase in urine and blood

The early symptoms of abdominal injuryShock, especially hemorrhagic shock.

Severe constant abdominal pain, nausea, vomiting

and signs of acute peritonitis.

Shifting dullness present and diminished liver dullness

Vomiting of blood, passing bloody stool or urine

PR examination: tenderness, pulsating swelling may be detected and there maybe blood on gloves

X-ray examination of the chest and abdomen

Abdominal puncture

valuable in difficult cases

Diagnostic Peritoneal lavage(DPL)

more reliable technique , accurately reflects the

presence of significant visceral damage in about

95% of cases

Additional diagnostic modalities

Ultrasonography noninvasive, can detect hemoperitoneum and solid organ injury

CT scan --- highly accurate diagnostic modality Hemodynamically stable patient with an equivocal abdominal examination Patient with closed head injury Patient with spinal cord injury Hematuria in the stable patient Patient with pelvic fractures and significant bleeding

• Observation

If the patient still can not be diagnosed with

the above methods, the patient must be kept in

hospital under strict observation until the

diagnosis can be made clearly.

The rules of management during observation Absolute rest Restricting of diet and intravenous infusion Don’t use morphe or any sedatives Measuring BP, pulse rate, respiratory rate and temperature at definite intervals repeat abdominal examination and blood count If there is any doubt of gastric perforation, gastric

suction and antibiotics should be used

• Performing exploratory laparotomy if necessary Indication:

Increased tenderness or rigidity or distension

Evidence of continuing blood loss that can not

be clearly explained by extraabdominal source

Evidence of developing peritonitis

The presence of free air on X-ray

Enlarging of intraabdominal mass

Demonstration of blood, bile, intestinal

contents in abdominal puncture

High amylase level in abdominal fluid

In the presence of shock with increasing

abdominal rigidity and an inadequate

response to fluid replacement

Treatment principleKeep the airway free

Circulatory resuscitation

laparotomy

Control of hemorrhage, in extreme cases thoracotomy required

Contamination from lacerations of the gut should be stopped as quickly as possible

spleen injury Spleen is the most commonly injured intra-

abdominal organ

Splenic injury must be suspected in any patient

with blunt abdominal trauma, especially with left

lower rib fracture

Diagnosis is suspected on physical examination,

and confirmed by abdominal CT scan or explora-

tory laparotomy for hemoperitoneum

TreatmentSplenorrhaphy or partial resection

Total splenectomy hilar vascular injury

massive subcapsular hematoma

extensive fragmentation

total avulsion

severe associated injuries

continuing bleeding after attempted splenic repair

Nonoperative management

delayed spleen rupture must be considered

due to enlarging subcapsular hematoma

rupture of a traumatic

pseudoaneurysm

recurrent or ongoing hemorrhage

Liver and Biliary Tree The second most commonly injured organ following blunt traumaInjury is ofen minor and can be easily managed by direct suture ligation or by using hemostatic agents

Seven basic techniques in operationSutureInflow occlusionPacking Hepatic artery ligation ResectionMesh hepatorrhaphyAtrial-caval shunting

Common bile duct injuryCompletely transection or >50% injured

biliary-enteric anastomosisPerforated or <50% injured

primary repair and place a T-tube

Cholecystostomycholecystectomy

Gallbladder injury

Stomach injury Gastric rupture secondary to blunt

trauma is rare Iatrogenic gastric rupture vigorous ventilation with an endotracheal

tube misplaced in the esophagus

If vomitus or gastric aspirate is bloody, stomach injury should be suspected

At laparotomy, gastrocolic omentum must be widely opened for complete inspection

Treatment

Debridement and closureGastric diversion or resection is

rarely necessary

Small intestion injury Incidence 5% -- 15% MechanismCrush injury between the vertebrae

and anterior abdominal wallSudden increase of intraluminal

pressureTear at the junction of a mobile and a

fixed segment of bower

TreatmentSimple laceration --- suture, avoid excessive

narrowing of the bowelExtensive damage or multiple tears situated

fairly close --- resection of the involved segment

Colon injuryMost colon injuries can only be definitively

recognized at laparotomy.

Early diagnosis and treatment dramatically reduce infection complications.

Four tecniques in the managementPrimary repairResection and primary anastomosisExteriorization of repair colostomy

Guidelines of repair instead of colostomyOperation within 4 to 6 hoursLess than 6 units of blood transfusionNo evidence of prolonged shock or

hemodynamic instabilityMinimal soilage of peritoneal cavityInjury limited to one aspect of the colonNo associated colonic vascular injuryNo loss of abdominal wall

Rectum injuryAbdominal x-ray films are obtained for

the determination of retroperitoneal airProctosigmoidoscopy performed for

either direct visualization of the injury or for the evidence of hemorrhage

Transpelvic gunshot wounds should undergo celiotomy

TreatmentFull thickness rectal wounds above the

dentate line --- primary closure combined with a diverting colostomy

Wounds below the dentate line --- debridement accompanied by drainage

Wounds above the levators with penetration of the pelvirectal space Closure, if possibleProximal diverting colostomyPresacral (retrorectal) drainageIrrigation of the rectal stump