Postgrad Med J: first published as 10.1136/pgmj.62.725.155 on 1 March 1986. Downloaded from Postgraduate Medical Journal (1986) 62, 155-158 Review Article Assessment and management ofthe injured abdomen T.G. Parks Department ofSurgery, The Queen's University ofBelfast, Belfast, UK. In many countries trauma remains the major cause of incipient paralytic ileus, significant injury should be death in patients under 40 years of age. Severe blunt strongly suspected. abdominal trauma occurs most often as a result of In patients with multiple injuries, abdominal road traffic accidents but it is not uncommon in trauma may represent a major challenge in diagnosis industrial injuries, civil violence or participation in and treatment. In other instances there may be no sport. The death toll in the European Economic significant injury to the abdomen but this may be Community from road traffic accidents alone totals difficult to substantiate with certainty initially. 50,000 per year. Furthermore, for every fatality there Altered level of consciousness due to head injury, are 20 cases ofserious injury. With improved transport presence of concurrent chest or skeletal injuries, services and vigorous resuscitative measures more of hypovolaemia and shock may add to the problems of these critically ill patients are surviving long enough to diagnosis in cases of abdominal trauma. reach the operating theatre for emergency surgery. A diagrammatic representation of a suggested The wearing of automobile seat belts has not only scheme for the clinical management of patients with reduced the mortality but also the frequency and penetrating and non-penetrating injuries is given in copyright. severity of injuries. However, the belt itself may cause Figure 1. intra-abdominal injury, particular if misplaced pres- sure acts directly on the abdomen rather than on the chest and iliac bones. The commonest intra- Blunt abdominal trauma abdominal injury is to the small bowel or its mesentery but other intra-abdominal organs are also at risk. Inaccuracy of clinical evaluation Patients with seat belt marks should be admitted for If observation. there is persistent abdominal pain or On the initial clinical assessment the diagnosis will in http://pmj.bmj.com/ all probability be accurate in only 70-80% ofcases. In ABDOMINAL INJURY those patients who have concomitant head injury, multiple trauma or are shocked on admission, the INITIAL ASSESSMENT correct clinical diagnosis may be made in less than RESUSCITATION 60% (Bivins et al., 1978). In patients with blunt abdominal trauma in whom PENETRATING NON-PENETRATING physical signs are absent or apparently trivial initially, GUNSHOT STAB CLINICAL EVALUATION significant lesions become manifest in up to one-third on September 25, 2021 by guest. Protected WOUNDS WOUNDS of cases (Bagwell & Ferguson, 1980). Thus, close BLAST GY PERITONEAL LAVAGE observation and repeated physical examinations are of LOCA CONTRAST STUDIES paramount importance. Aids to diagnosis LAPAROTOMY LAPAROTOMY OBSERVE OBSERVE LAPAROTOMY Table I lists various investigations which may aid in Figure 1 Suggested scheme for the clinical management of the diagnosis of non-penetrating abdominal trauma. patients with abdominal trauma. In some instances none ofthese will be feasible because of the necessity to provide immediate resuscitation Correspondence: T.G. Parks, M.Ch., F.R.C.S., Department and proceed to urgent laparotomy. of Surgery, Institute of Clinical Science, Grosvenor Road, X-ray of the abdomen and chest may demonstrate Belfast BT12 6BJ free intra-peritoneal gas from a ruptured hollow Accepted: 9 October 1985. viscus. Retroperitoneal rupture ofthe duodenum may A) The Fellowship of Postgraduate Medicine, 1986 Postgrad Med J: first published as 10.1136/pgmj.62.725.155 on 1 March 1986. Downloaded from 156 T.G. PARKS Table I Blunt abdominal trauma radioisotopic or ultrasonic techniques as aids to diagnosis. It should be stressed however that it is only Aids to diagnosis: in a relatively small percentage of cases of abdominal trauma that these latter are indicated. Abdominal and chest X-rays techniques Serum amylase Paracentesis Peritoneal lavage Penetrating wounds Urinalysis Urinary tract radiography Penetrating wounds are most often due to stabbing or Radioisotope scans of liver and spleen gunfire. The size of the external wound bears little Ultrasonography relationship to the depth of the penetration and the Computerized axial tomography severity ofinternal injury. Since the diaphragm rises as Gastrointestinal tract studies high as the fourth intercostal space during expiration, Biliary tract studies any patient with a penetrating wound below this level anteriorly or the fifth intercostal space laterally or the sixth intercostal space posteriorly should be con- give rise to air bubbles around the right psoas and sidered potentially at risk for a subdiaphragmatic kidney, obliteration of the psoas margin, scoliosis or injury. With gunshot wounds the bullet entering the segmental ileus. Rupture of the diaphragm, more chest at any level may pass in an oblique or vertical common on the left than the right, may be demon- rather than a horizontal plane through the chest and strated by gas filled organs in the chest. hence enter the abdomen. Four quadrant peritoneal aspiration using a fine Plain X-rays of the abdomen may yield useful needle is helpful when positive but negative results information following penetrating abdominal should not be allowed to cloud the clinical acumen of wounds. However, sinography in which a radio- the surgeon or lead to complacency. Although the opaque medium is used to outline the tract is unrelia- method is simpler than diagnostic peritoneal lavage it ble in determining whether or not the peritoneum has is much less accurate as a diagnostic procedure and in been penetrated in stab injuries (Aragon & Eiseman, copyright. many centres has been abandoned. The recent 1976). Furthermore, probing is inaccurate in deter- modification whereby the peritoneal cavity is tapped mining the depth of the stab wound and may open up in the paracolic gutter with the patient inclined to the false tracts or introduce infection (Petersen & Sheldon, side may lead to improved accuracy of the method. 1979). Peritoneal lavage if expertly carried out is now Exploration is mandatory in all gunshot wounds of accepted as a relatively safe diagnostic procedure and the lower chest and abdomen. When the missile has is accurate in up to 98% of cases in determining the entered the peritoneal cavity, significant lesions are presence or absence ofintra-abdominal injury follow- present in 92-98% of cases. Serious intraperitoneal ing blunt trauma (Fischer et al., 1978). However, in injury due to shock waves may occur without penetra- http://pmj.bmj.com/ cases of injury of the retroperitoneal portion of the tion of the peritoneal cavity, especially in abdominal colon, duodenum or pancreas, the technique is trauma caused by high velocity weapons. notoriously inaccurate. Likewise, isolated bladder and The management of abdominal stab wounds is a diaphragmatic rupture may yield misleading results. more controversial topic. For many years most sur- Potential complications of lavage include perforation geons routinely explored stab wounds ofthe abdomen of the small intestine and colon, injury to the mesen- but in recent years many surgeons have adopted what or or teric iliac vessels, to the bladder. In a prospective they consider to be a more rational approach to on September 25, 2021 by guest. Protected randomized trial undertaken by Pachter & Hofstetter management of such injuries. (1981), the open method in which the catheter is When a distinct policy of selective exploration of inserted through the peritoneum under direct vision abdominal stab wounds was adopted by Nance et al. was shown to be safer and more accurate than the (1974), their negative exploration rate fell from 53% to percutaneous method. 11% and complication rate fell from 14% to 8%. In a In patients with a suspected urinary tract injury, large series of 403 cases of abdominal stab wounds urinalysis and intravenous urography may reveal the reported by Wilder & Kudchadkar (1980), 216 type and degree of injury. The absence ofexcretion of patients were observed and only 16 of these sub- the contrast by one ofthe kidneys may indicate a renal sequently came to surgery (all within 24 hours) with no pedicle injury, warranting arteriography for confirma- obvious detrimental effects due to this period ofdelay. tion. These authors relied very much on careful and re- In difficult cases, particularly those presenting with peated clinical examinations and only occasionally less acute signs, useful information may be obtained undertook peritoneal aspiration or lavage. by employing more sophisticated radiological, Surgery is clearly indicated if there is evidence of Postgrad Med J: first published as 10.1136/pgmj.62.725.155 on 1 March 1986. Downloaded from THE INJURED ABDOMEN 157 evisceration, pneumoperitoneum, haemoperitoneum, For minor contusions ofthe pancreas simple drain- peritoneal irritation or hypovolaemia and circulatory age is adequate. For moderate or severe injuries ofthe inadequacy for which there is no other obvious cause. body of the pancreas involving the main pancreatic Likewise, if blood appears from the stomach, rectum duct, distal pancreatectomy is preferable to more or bladder, exploration must be undertaken. On the conservative options. While many lacerations of the other hand, if peritoneal