Abdominal Injuries

Prof. NAA Mbembati

MD5 lecture

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Introduction
Injuries of the abdomen may be penetrating or non-
penetrating.
Penetrating injuries are more common as military
injuries although they can also occur in civilian life as a
result of assault.
Non-penetrating injuries are more common in civilian
life and are mostly a result of road traffic injuries.

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Pathophysiology
 In penetrating injuries the injured organ may be predicted
by the site of the external wound but in blunt abdominal
injuries this may be difficult.
 In both cases the diagnostic difficulties may be made more
difficult by drugs or alcohol intoxication or multiple system
injuries including brain injury.
 Penetrating injuries may produce evidence of intra-
abdominal organ involved by the site of skin wound
impalement or evisceration.
 Abdominal organ injury should also be suspected in
injuries of the chest, back, buttocks or thigh especially in
missile injuries.

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Penetrating inujury

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Penetrating Injury

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Pathophysiology ctd
 Blunt abdominal injuries are more difficult to diagnose
as they are often associated with other injuries e.g.
Head injury, fractures of long bones, extensive tissue
injuries and shock.
 Abdominal distension/increasing abdominal girth and
pain should increase suspicion

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Pathophysiology ctd
 Solid organsbleed heavily leading to shock
 Liver
 Spleen

 Kidneys
 Pancreas

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Pathophysiology ctd
 Hollow organs-rupture will cause spillage of contents
and preritoneal inflammation
 Stomach
 Gall bladder
 Bowel
 Ureters
 Urinary bladder

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Pathophysiology ctd
 Major vesselsinjury can cause severe blood loss with
exanguination:
 Aorta
 Inferior vena cava
 Major branches(Iliac, femoral)

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Presentation

 This includes abdominal pain, nausea and vomiting, anxiety

thirst and air hunger in the conscious patient.
 In an unconscious patient abdominal trauma will have to be
kept in mind on physical examination where there may be
evidence of wounding effect, severe contusion or ecchymosis,
but also in fracture of pelvis and lower ribs.
 Abdominal tenderness, shifting dullness, absence of bowel
sounds.
 Digital rectal examination may reveal blood in which case
rectal trauma should be suspected.
 Shock in absence of external blood loss: supect intra-
abdominal trauma until proven otherwise.

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Physical Examination and management
 Do ABCDs of shock: airway+/-intubationventillation
 I/V lines R/L, N/S or Blood
 Catheterize
 Nasogastric tube

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Management (continued)
 Perform the secondary survey: a complete physical
examination to evaluate the abdomen and to establish
the extent of other injury.
 Examine the abdomen for bowel sounds, tenderness,
rigidity and contusions or open wounds.
 Administer small doses of intravenous analgesics,
prophylactic antibiotics and tetanus prophylaxis.

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Investigations

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Investigations-FAST

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Diagnostic Peritoneal Lavage
 If the diagnosis of intra-abdominal bleeding is uncertain,
proceed with diagnostic peritoneal lavage.
 Laparotomy is indicated when abdominal trauma is
associated with obvious rebound tenderness, frank blood
on peritoneal lavage or hypotension and a positive
peritoneal lavage.
 Serial physical examination, ultrasound and X-rays are
helpful in the equivocal case.
 X-ray the chest, abdomen, pelvis and any other injured
parts of the body if the patient is stable. If you suspect a
ruptured viscus, a lateral decubitus abdominal X-ray may
show free intraperitoneal air.

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Diagnostic peritoneal lavage

After the primary survey, resuscitation and secondary

survey have been completed, the findings indicating
intra-abdominal bleeding or lacerated viscera may not
be adequate to confirm diagnosis. Serial physical
examination can be supplemented with diagnostic
peritoneal lavage (DPL) to make a decision on whether
trauma laparotomy should be performed.

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Indications for exploratory laparotomy
 Obvious peritoneal signson physical exam
 Abdominal Distension +shock
 Abdominal gunshot wounds
 Penetrating wounds with evisceration, impalement,
peritonitis or hypotension
 Positive FAST or other investigations eg airunder the
diaphragm, +ve CT scan

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Exploratory laparotomy
 Extended midline incision- for easy access to all
corners of abdomen.
 Evacuate blood-(consider autotransfusion)
 Explore all quadrants , from diaphragm to pelvis.
Look at all potential organs for injury
 Exclude rupture of the diaphragm. Deal eith specific
injury accordingly.

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Ruptured Spleen

 In tropical countries, splenomegaly due to malaria or

visceral leishmaniasis is common. The affected spleen is
liable to injury or rupture as a result of trivial trauma.
 Delayed rupture can occur up to three weeks after the
injury.
 Consider conservative management, particularly in
children, if the patient is stable and you are able to
monitor him closely with bed rest, intravenous fluids,
analgesics and nasogastric suction.
 Perform a laparotomy (and splenectomy) if you suspect a
ruptured spleen and the patient is hypovolaemic

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Liver Injuries

 Liver injuries follow blunt trauma to the right upper

quadrant of the abdomen and may result in significant
bleeding .
 Many liver injuries stop bleeding spontaneously and
you should not suture them as this may result in
significant bleeding which is difficult to stop.
 Large liver lacerations should not be closed; bleeding
vessels should be ligated and the liver defect packed
with omentum or, if this is unsuccessful, with gauze.
 A large drain is indicated in all patients with liver
injuries. It should be removed after about 48 hours
unless bile continues to drain. 21
Kidneys
Kidneys

Do not expose the kidney unless there is life-

threatening bleeding. An expanding or pulsating
haematoma is evidence of such bleeding. Stop the
bleeding at the site of the tear with stitches. Consider
the need for specialized surgery.

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Rupture of the Urinary Bladder
 Extraperitoneal rupture
Extraperitoneal rupture is most commonly associated with
fracture of the pelvis, resulting in extravasation of urine
The patient may pass only small drops of blood when
attempting to pass urine. A significant feature is swollen
soft tissues of the groin extending to the scrotum, due to
extravasated urine.
 For extraperitoneal rupture, construct a suprapubic
cystostomy; if the rupture is large, also place a latex drain

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 Intraperitoneal rupture

Intraperitoneal rupture is often the result of a direct

blow to the bladder or a sudden deceleration of the
patient when the bladder is distended, for example in
a road traffic accident Intraperitoneal rupture
presents as “acute abdomen”, with pain in the lower
abdomen, tenderness and guarding associated with
failure to pass urine.

 For intraperitoneal rupture, close the rupture and

drain the bladder with a large urethral catheter or a 24