Surgical paper XIIIX
Abdominal trauma, encompassing injuries to both the abdominal wall and internal viscera, is a prevalent medical issue. While the severity of the injury is undoubtedly a significant factor, early diagnosis and appropriate treatment are equally crucial. However, healthcare providers often encounter specific challenges and pitfalls, such as:
Common Pitfalls in Diagnosis and Treatment
Unknown Medical History: The inability to obtain a valuable medical history due to patient coma or overlooked minor trauma.
Subtle Early Symptoms: Lack of apparent signs in the immediate aftermath of the injury, making diagnosis challenging.
Delayed Visceral Rupture: Instances of late-onset rupture that go unnoticed during the initial evaluation.
Distracting Injuries: Concomitant severe injuries, such as cerebral or thoracic trauma, that divert attention away from abdominal injuries.
Misdiagnosis Due to Spinal Involvement: Abdominal signs resulting from lower thoracic spine and chest injuries that may be mistaken for abdominal trauma.
Conservative Approach: An overly cautious attitude, especially when the abdominal wall appears intact, can lead to missed diagnoses and lost opportunities for timely intervention.
abdominal trauma refers to injuries to the abdominal wall or internal organs, or both, caused by external force.
Mechanisms of Injury
Direct Impact: Blunt force trauma to the abdomen.
Indirect Impact: Falls from heights, seismic shocks, and other indirect forces.
Non-penetrating Injury: Injuries resulting from vehicular accidents.
Penetrating Injury: Wounds from knives, guns, or explosions.
Categories of Abdominal Viscera
Solid Organs: Liver, spleen, kidney, pancreas.
Cavitary Organs: Stomach, intestines, bladder, gall bladder.
Structural Components: Mesentery, peritoneum, nerves, blood vessels.
Risks and Complications
The main risk of trauma to solid organs and stent structures is hemorrhage; the main risk for hollow organ trauma is the infection caused by the contents overflowing into the abdominal cavity, leading to peritonitis.
In fact, any visceral trauma can result in fatal hemorrhage. Liver and spleen injuries, in particular, can lead to long-term, persistent, and recurrent bleeding. This is because the blood vessel walls of these organs are thin, and the organs themselves are fragile and lack elasticity. Therefore, effective vessel constriction and blood clot formation may not occur. Moreover, once bleeding stops, due to the rich blood supply to these organs, a rise in blood pressure can wash away the hemostatic clot, leading to recurrent bleeding.
The likelihood of hollow organ injury is related to the amount of contents it holds (those with a full stomach are more susceptible to injury); it is related to the degree of fixation (the distal and proximal ends of the small intestine, and the hepatic and splenic flexures of the colon are vulnerable); and it is related to pre-existing conditions (those with prior illnesses are more susceptible to injury).
The nature of substances that irritate the peritoneum determines its pathological changes and abdominal signs:
Gastrointestinal bacteria increase from top to bottom, such as in the case of fecal peritonitis due to colon injury, which has a very strong infectious nature.
The chemical irritability of the gastrointestinal tract decreases from top to bottom, such as in the case of chemical peritonitis caused by perforations in the stomach or duodenum, which can be very severe.
Bile and urine may or may not contain bacteria, but they are chemical mixtures that can lead to peritonitis, albeit a bit later in time.
Blood without bacteria causes minimal irritation to the peritoneum, so the reaction to hemorrhagic peritonitis is usually mild.
Gas irritation of the peritoneum can also produce symptoms.
Regardless of the nature of the material that spills into the abdominal cavity, it often follows its natural drainage route with the peritoneal exudate it produces, leading to the paracolic gutter and the pelvic floor, resulting in intestinal paralysis and abdominal distension.
Symptoms and Signs
Fainting or Shock:
- Abdominal wall contusions are rare, but visceral injuries are common. Substantial visceral organ rupture can cause massive bleeding and can be extremely dangerous. Damage to major blood vessels can be immediately fatal and beyond rescue. Peritonitis due to the perforation of hollow organs leads to toxic shock.
- Contusions to the abdominal wall are localized and minor; visceral injuries are extensive and persistent.
- Progressive worsening is a sign of internal bleeding and peritonitis, with inhibited abdominal breathing. However, attention must also be paid to intestinal motility inhibition caused by retroperitoneal injuries and hematomas that stimulate the abdominal plexus.
- Point muscle guarding, tenderness, and rebound tenderness can often indicate the site of injury in the early stages. In the later stages, it becomes generalized and is often corroborative evidence of visceral injury.
Nausea and Vomiting:
- Reflexive in the early stages and due to backflow in the later stages.
Liver Dullness Boundary:
- Abdominal gas distension can cause it to shrink, and a free air layer can make it disappear. After liver rupture, the dullness boundary expands.
- Often a significant basis for abdominal hemorrhage or effusion.
- Reflexively weakened in the early stages, leading to an “inactive abdomen” caused by inflammation in the later stages.
The central issues in diagnosing abdominal trauma are to clarify:
- Is it a simple abdominal wall injury, or is there also visceral injury?
- Which organ(s) are injured, and is it a single or multiple injuries?
- What is the volume and rate of internal bleeding, and has it stopped or is it ongoing?
A detailed medical history should be obtained, including the magnitude and direction of the force, posture at the time of injury, and subsequent reactions such as sudden sharp pain, fainting, and vomiting. Physical examination should include evaluation of muscle guarding, the scope of tenderness, dullness and tympanic areas, and their changes. Body temperature, pulse, respiration, blood pressure, blood and urine tests, X-rays, and ultrasound should be measured. The use of analgesics like morphine should be avoided during observation, except when a diagnosis has been confirmed and surgery is planned. If necessary, exploratory laparotomy should be performed; it’s better to act than to miss the opportunity, even if no significant findings are obtained.
Blood Count: An elevated white blood cell count in the early stage is a physiological response to trauma. Some believe that internal bleeding can produce a large amount of hematopoietic stimulants, leading to an elevated white blood cell count when absorbed by the peritoneum. Peritonitis naturally causes elevated white blood cells and a left shift in neutrophils. Internal bleeding presents as anemia.
Hematuria: A strong basis for urological injuries and an effective indicator for monitoring the outcome of the injury.
X-Ray: Free air under the diaphragm is generally considered to have only a 50% positive rate, and attention should be paid to it. Comparison of the diaphragmatic height and movement on both sides can aid in the diagnosis of liver and spleen injuries.
Abdominal Paracentesis: Highly valuable. The characteristics and state of the extracted fluid can often confirm the diagnosis. Because a positive result requires more than 200 ml of fluid in the abdominal cavity, some use lavage to increase the positivity rate. If unsuccessful, change the needle direction and depth or reattempt after an interval. Besides macroscopic observation, amylase quantification and smear tests can be done on the puncture fluid. The presence of multiple types of bacteria without pus cells or the presence of parasitic eggs supports the hypothesis of accidental intestinal entry.
Rectal Examination and Posterior Fornix Puncture in Married Women: These can be included as routine examinations to help with early diagnosis.
Management and Treatment
Shock Management: For patients in shock, use a slight incline position and elevate both legs (to facilitate breathing and venous return). Measures like warming, fluid resuscitation, blood transfusion, oxygen administration, and antibiotics are essential. Given the peritoneum’s strong anti-infective ability, fatalities due to infection are far less common than those due to shock or bleeding. Therefore, establishing an open vein and rapidly restoring effective blood volume is of utmost importance.
Surgical Intervention: Surgery for abdominal injuries should ideally be performed within 6 hours. If anti-shock measures are ineffective, forced surgery should be performed to eliminate the source of the problem as one of the life-saving measures.
Surgical Incision: The location of the incision is determined based on the estimated site of injury. The principle is to make the incision as close and convenient as possible to the affected area. A midline vertical incision is generally used, as it allows for quick entry and is easily extendable. Before closing the abdomen, it’s crucial to thoroughly wash and aspirate the abdominal cavity. For contamination with bile, pancreas, feces, or urine, drainage should be implemented.
Specific Injuries and Treatments
Spleen Rupture: Standard procedure is removal. Some recent studies advocate for repair in minor injuries to preserve spleen function. Autotransfusion of the patient’s own blood can be done without anticoagulants, saving resources and avoiding citrate toxicity.
Small Intestine Rupture: Repairs or resection and anastomosis are the go-to approaches. Externalization of the intestine is less preferred.
- Type of Injury: Most liver injuries involve a laceration of the liver tissue, which largely remains intact due to the resiliency of its blood vessels.
- Surgical Interventions: During surgery, the focus is on debridement and individual ligation of severed blood and bile ducts. Further harm to the liver should be avoided. Full-layer mattress sutures are generally used, and the omentum is often laid over the sutured area. Sometimes, omentum or muscle can be used for packing. Gauze packing should be avoided.
- Limited Crush Injuries: For localized crush injuries, partial hepatectomy is recommended.
- Control of Bleeding: If there is profuse bleeding during surgery, temporary occlusion of the hepatic portal can control it (up to 15 minutes at room temperature is allowed). If bleeding can’t be controlled, ligation of the hepatic artery often works immediately.
- Post-Operative Considerations: Adequate drainage below the liver is crucial, often with the additional step of controlled decompression of the common bile duct.
Suturing and Complications:
- Suture Material: Both intestinal thread and silk thread are acceptable, although the author believes that No. 4 silk thread is preferable.
- Tightness of Ligations: Ligations should not be too tight; they should be just tight enough to control bleeding. Over-tightening can lead to complications like hepatic necrosis, delayed bleeding, or bile leakage.
- Anecdotal Experience: The author recounts a case of postoperative massive biliary bleeding on Day 21, which required another surgery to ligate the intrinsic hepatic artery.
- Caution with Bile-Contaminated Blood: Normally, blood contaminated with bile should not be transfused back. However, an anecdotal case saw 1500 mL transfused without adverse effects in a rural setting. It’s generally considered safe to transfuse one’s own blood back if there are no injuries to the extrahepatic biliary tract.
Colon Injury: Early repair is recommended; late-stage injuries may require externalization and later resection and anastomosis.
Mesenteric Tear: Repair and hemostasis are essential. If blood supply to the intestines is compromised, resection may be needed.
Pancreatic Injury: Small tears can be sutured, and the pancreatic duct can be ligated if damaged. For injuries to the head of the pancreas, reimplantation is necessary to establish a new pancreatic-intestinal pathway.
Stomach and Duodenal Injuries: Repair is standard. Special attention should be given to retroperitoneal injuries of the duodenum.
Extrahepatic Biliary Tract Injury: Repair, fistula creation, and external drainage are options.
Kidney Injury: Generally conservative treatment under close observation is sufficient due to the kidney’s high regenerative capacity.
10. Extrarenal Urinary Tract Injury: Injuries to the ureter are rare. Bladder injuries are more common and often associated with pelvic fractures. Repair, fistula creation, and drainage are usual treatments.
11. Diaphragm Injury: More commonly seen on the left side, resulting in diaphragmatic hernia and bleeding. High mortality rates necessitate early thoracic repair.
12. Retroperitoneal Major Vascular Injury: Repair is generally performed unless immediate intervention is not possible. For injuries to the inferior vena cava below the renal veins, ligation is an option.
- General Treatment: Unless the injury is too severe to be managed emergently, the usual approach is to repair the damaged vessel.
- Below the Level of the Renal Vein: Injuries to the inferior vena cava below the level of the renal veins can generally be managed by ligation and cutting off the damaged segment.
- Above the Level of the Renal Vein: For injuries to the inferior vena cava above the level of the renal veins, if repair is not possible, some advocate for ligation. However, this necessitates the removal of the right kidney. The left kidney can rely on collateral circulation (e.g., adrenal vein) and should be unaffected. However, this approach could lead to insufficient venous return to the heart.
Determining whether the injury is confined to the abdominal wall or involves internal organs is crucial for making timely decisions about surgical intervention and life-saving measures. A simple contusion of the abdominal wall can also lead to symptoms like abdominal pain, muscular guarding, and localized tenderness due to muscle bruising and bleeding, which can irritate the peritoneum. These symptoms may even be accompanied by nausea and vomiting. On the other hand, early signs of internal organ damage can be subtle due to minimal initial bleeding and leakage, which may be diluted by intraperitoneal fluid. This makes it easy to confuse the two types of injuries.
Abdominal Wall Contusion:
In cases of abdominal wall contusion, the abdominal pain is usually mild, muscular guarding is localized, and there may be subcutaneous bruising and soft tissue swelling. Generally, systemic disturbance is minimal, and shock is unlikely.
Solid Organ Rupture:
For solid organs, except for the liver and gallbladder, the symptoms of peritoneal irritation are generally less severe compared to hollow organ injuries. While pain may be felt throughout the abdomen, it is most prominent in the area where the damaged organ is located. The following points can assist in the diagnosis:
Indicators of Internal Bleeding: After trauma to the lower chest and upper abdominal area, there may be signs of internal bleeding, such as an increased pulse rate, a drop in blood pressure, progressive anemia, and the absence of abdominal breathing.
Pain Radiating from the Ribcage: Abdominal pain may be most pronounced in the costal margins and may radiate to the shoulders, back, and waist.
Persistent Upper Abdominal Pain: After the injury, pain in the upper abdomen persists and may be accompanied by localized tenderness, muscular guarding, abdominal distension, and reduced bowel sounds.
Changes in Liver or Spleen Percussion: On X-ray, there may be an enlargement of the liver or spleen shadow, elevation and reduced movement of the diaphragm on the injured side, and disappearance of the psoas muscle shadow.
Presence of Fixed or Shifting Dullness: During abdominal paracentesis, non-clotting dark red blood may be observed. This is due to defibrinated blood, which is also associated with the action of fibrinolysin.
Diagnosis of Hollow Organ Perforation:
Perforation of hollow organs often leads to peritonitis at an early stage, characterized by severe abdominal pain that makes early detection easier. The following points can assist in diagnosis:
Severe Abdominal Pain Lasting Over 4 Hours: This is accompanied by:
- Nausea and bilious vomiting
- Increased pulse rate
- Fixed tenderness upon palpation
- An expanding area of muscular guarding
- Elevated white blood cell count with a leftward shift in differential
- Weakened or absent abdominal breathing
Anemia Not Prominent but Rapid Pulse and Restlessness: Even if anemia is not obvious, a fast pulse rate and symptoms of restlessness or agitation may be present.
Disappearance of Liver Dullness: An X-ray may show the presence of free air under the diaphragm, indicating perforation.
Abdominal Paracentesis Shows Turbid Fluid: Microscopic examination confirms the presence of pathogens, indicating infection.
Early Diagnosis and Treatment:
For patients with multiple injuries, if there is even one reliable indicator, early exploratory laparotomy is advised.
Conditions for Conservative Treatment:
- Injury is confined to the abdominal wall.
- Although there’s internal bleeding, it has stopped and there are no signs of hollow organ perforation; vital signs remain stable.
- General condition is still good one or two days post-injury, and any internal infection is localized.
- Mild kidney injuries where the hematuria gradually decreases and pain subsides.
Complete anesthesia is required to relax the abdominal muscles, facilitating exploration and cleaning of the abdominal cavity. Our majority of cases have safely and satisfactorily used continuous epidural anesthesia, but it should be administered in small, slow doses. Note that the required dosage for these patients is generally less than for typical patients.
Pay attention to the existence of compound injuries to avoid overlooking any. Check retroperitoneal organs like the duodenum, colon, and the bare area of the liver. The omentum often points to the location of the pathology.
Suggested Order of Exploration:
Spleen, liver, pancreas, diaphragm, base of the stomach, bile ducts, duodenum, mesentery, omentum, small intestine (from the jejunum to the ileocecal region), large intestine (note the hepatic and splenic flexures), retroperitoneal organs like kidneys and major blood vessels, and pelvic organs.
The decision to drain is based on the timing of the injury, the degree of infection, and the quantity and quality of the intra-abdominal fluid. For early abdominal contamination, thorough washing is the main approach, supplemented by drainage. Drainage is necessary for liver, gallbladder, pancreas, and intestinal injuries.
Early death is usually due to severe compound injuries, traumatic shock, and major bleeding. Late death often occurs from generalized peritonitis, toxic shock, and water and electrolyte imbalances. The cure rate for surgical cases can reach around 90%.
- Huang Jiaqi, “Surgery,” People’s Health Publishing House, P: 497, 1964.
- Gao Xianming, “Abdominal Trauma,” Journal of Surgery, 6: 468, 1951.
- Jiang Kegou, “Diagnosis and Treatment of Abdominal Trauma,” Journal of Surgery, 6: 376, 1951.
- Huang Wen, “Clinical Analysis of 98 Cases of Abdominal Contusion,” Chinese Journal of Surgery, 4: 370, 1960.
- Gong Songnan, “Closed Abdominal Injury (with analysis of 220 cases),” Chinese Journal of Surgery, 15: (2) 96, 1977.
Originally published in "Nanling Medical Journal" by Li Mingjie, Department of Surgery, Nanling County Hospital, 1979; 59-63.