|Year : 1996 | Volume
| Issue : 8 | Page : 272-276
Blunt trauma abdomen: A study of 63 cases
Shalu Gupta, S Talwar, RK Sharma, P Gupta, A Goyal, P Prasad
Department of General Surgery J.L.N. Medical College & Hostiital, Ajmer, India
|Date of Submission||25-May-1995|
Department of General Surgery J.L.N. Medical College & Hostiital, Ajmer
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta S, Talwar S, Sharma R K, Gupta P, Goyal A, Prasad P. Blunt trauma abdomen: A study of 63 cases. Indian J Med Sci 1996;50:272-6
The rapid pace of industrialization coupled with an increase in the number of automobiles and vehicular accidents is giving us an increased incidence of blunt abdominal trauma (BAT) which is the 3rd commonest form of trauma. It is seen with increasing frequency in emergency rooms and continues to be associated significant morbidity and mortaIity in spite of its improved recognition, diagnosis and management. This study endeveours to evaluate 63 cases of BAT with stress on early diagnosis and management.
| ¤ Material and Method|| |
63 cases of BAT presenting to this hospital were included in this study. A detailed clinical history was obtained in each case. Detailed physical examination, laboratory tests and X-rays were done to arrive at a diagnosis. In all cases, 4 quadrant abdominal paracentesis was carried out. The progress of the patient was closely monitored and a decision was taken to either continue with conservative management or to undertake laporotamy. Patients who did not respond to conservative treatment and continued to deteriorate despite adequate resusication and those patients who had haemoperitoneum or evidence of gas under diaphragm on X-ray flat plate abdomen were taken for laparotomy; rest were treated conservatively. Finally inferences were drawn regarding the pattern of organ involvement, operative procedure, post operative complications, morbidity and mortality.
| ¤ Observations|| |
The age and sex distribution of the cases in our study is shown in [Table 1]. Automobile accidents accounted for 32 injuries. Falls 21, blows 6, and animal horn injuries 4. Majority of the patients presented with pain abdomen (62 patients) and vomiting (21 patients). Restriction of urinal (12) Hoematuria (8) Constipation (4) and Blood in stone (3). Generalized abdominal tenderness and guarding were present in 56 cases; 18 patients and hypovolumic shock. Rectal examination was not helpful. Microscopic haematuria was present in 12 cases, routine X-rays showed abnormalities like fracture ribs, haemathorax, pneumothorax etc. in 6 cases X-ray flat plate abdomen was abnormal in 22 cases; abnormal findings included evidence of gas under diaphragm in 14 cases, absent psoas and splenic shadows in 2 cases and dilated gut loops and fluid levels in 6 cases. Associated orthopaedic injuries, mainly fracture pelvis were present in 13 cases. In 7 patients, ultrasonography was done and it revealed pathology like renal laceration and reteroperi.otoneal haemetoma in 6 cases. In 1 case of haematuria, intravenous pyelography was done and was contributory to the diagnosis of renal laceration. Four quadra abdominal paracentesis was performed in all 63 patients. It revealed haemoperitoneum in 40 cases, a finding subsequently confirmed on laparotomy in all such cases.
In 40 cases there was no visible external injury but Subsequent laparotomy in 29 cases who had a positive diagnosic tap revealed internal injuries like liver, spleen, kidney, intestinal injury etc. Associated extra abdominal injuries were encountered frequently and then were fracture pelvis (6) fracture ribs (6) head injury (5) other injuries (3). These tended to increase the morbidity and mortality directly and indirectly by distracting attention from abdominal injury. Exploratory laparotomy was carried out in 43 cases. The pattern of visceral involvement is shown in [Table 2]. Liver was the commonest organ involved. Post operative complications like wound sepsis, subphrenic abscess and shock were encountered in 5 cases. Mortality in our study was seen in 7 cases majority being in the age group 21-30 years. Associated injuries such as head injury, multiple fractures were responsible for death in 3 cases. Poor pre-operative general condition such as shock, tachycardia and associated medical diseases were responsible for death in 4 cases.
| ¤ Discussion|| |
Out of the 63 cases included in our study, more than 87%/ were under 40 years of age. This is important as this is the most productive and active age group. Automobile accidents accounted for 50% cases. Other studies have also implicated automobile accidents as the leading cause of BAT. , Thus prevention of these could lead to a reduced incidence of BAT. Although majority of the patients presented with pain abdomen and vomiting and had generalized abdominal tenderness and guarding, yet 63.5% cases had no visible external abdominal injury and on laparotomy 72.5%, of these patients had definite visceral injury. This emphasizes the importance of careful and continuing observation of patients with Blunt Abdominal Trauma. It is in this group of patients that abdominal paracentesis may provide accurate and reliable information in the detection of intraperitoneal haemorrhage and visceral disruption. In our study, abdominal paramentesis revealehd haemoperitoneum in 40 cases, a finding subsequently confirmed on laparotomy in all such cases. Paracentesis can be performed rapidly without delay and requires no specialized equipment  and many studies have emphasized its use. Other investigations like lntravenous pyelography and ultrasonography were also helpful to arrive at a diagnosis in our study. Associated injuries, mainly orthopaedic, were encountered frequently. Care of the injuries in any of the systems may take precedence over abdominal trauma. Failure to recognize an extra abdominal injury may contribute to the patients's death when a relatively simple procedure might otherwise have saved the patient's life.  Laparotorny in our series was performed as per the criteria laid down above. The subtlety with which organ injury can exist secondary BAT is exemplified by the fact that 63.5% patients who did not have any visible external sign of internal injury were explored and 72.5% of these had an injury which required repair. Proper management of these patients requires careful initial evaluation followed by a period of observation.  Diagnostic procedures should be limited to those examinations that have proven effective in BAT and should not delay laparotomy in an unstable patient. One a seriously injured patient by obwining examinations of low yield. should not jeopardize the care of a seriously injured patient by obtaining examinations of low yield. Utilization of this time to initiate resusicative measures and to prepare for abdominal exploration is of much greater benefit to the patient. 
In our study, Liver was found to be the organ most frequently injured. This is contrary to the study by Davies et al where spleen was found to be injured most frequently' but is similar to the study by Allen et al in which liver was injured in 24.3% patients. BAT has always been associated with a high morbidity and mortality rate, various studies indicate a morbidity rate of 40% and a majority rate of 29%. , But in our study complications like cubphrenic abscess developed in only 1 case and there were 2 deaths, mcstly related to poor pre-operative general condition of the patient. This indicates that timely surgical intervention may be of great help in dealing with a traumatized liver. The 6 patients of splenic injury in our study recovered uneventfully although a morality rate of 20 has been reported in splenic trauma.  Kidney and urinary bladder injuries were frequently associated with pelvic fractures and reteroperitoneal bleeding  patients of renal injury died which was attributable to associated severe crush injury and reteroperitoneal haemorrhage. Nephrectomy was done in 1 case of extensive renal laceration and the patient recovered uneventfully, otherwise renal injuries were treated conservatively. In patients with urinary bladder injury, laparotomy followed by pair of the bladder was carried out and the patients recovered uneventfully. Majority of the patients of stomach, small and large gut injuries were treated with suture repair but in 1 case, resection of the injured bowel was carried out, death occurred in 2 patients of ileal injury due to shock. Only 2 duodenal injuries were recognized and the patients recovered uneventfully after undergoing debridement, primary repair and drainage. Blunt duodenal trauma rarely occurs as an isolated injury and this in part accounts for a continuing mortality rate of 20-25% and a high morbidity rate. , Retroperitoneal duodenal injury may be overlooked because of associated intra-abdominal injury.  Post operative complications like wound sepsis, subphrenic abscess, shock were encountered in only 5 cases. Mortality was seen in 7 cases. Majority of the deaths were related to associated injuries such as head injury, multiple fractures and poor pre-operative general condition such as shock, tachycardia and associated medical diseases. The figure can be reduced by early diagnosis, adequate patient resusication and early surgical intervention.
We conclude that internal abdominal injury mostly occurs in the absence of external injury. Hepatic trauma is the commonest. Mortality is related to delayed presentation and diagnosis, associated injuries and delayed surgical intervention. To improve the prognosis in such patients, a multi-pronged approach towards early diagnosis and prompt management should be instituted.
| ¤ Summary|| |
63 cases of blunt abdomina trauma were studied. It was more common In males and in the age group 21-30 years. Majority of the injuries were due to automobile accidents. Commonly presenting feature was pain abdomen and vomiting. Abdominal paracentesis revealed haemoperitoneum in 40 cases which was subsequently confirmed on laparotomy in all the cases. 40 cases had no visible external injury but subsequent laparotomy revealed internal visceral injury in 29 cases. Exploratory laparotomy was carried out in 43 cases, remaining were treated conservatively. Liver was found to be the commonest organ injured. Post operative complications developed in 5 cases and deaths occured in 7 cases mainly due to associated extra-abdominal injuries, poor pre-operative general condition, delayed diagnosis and management. We conclude that a multipronged approach towards early diagnosis and vigorous management should be adopted to reduce the morbidity and mortality in patients with blunt abdominal trauma.
| ¤ References|| |
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[Table 1], [Table 2]
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