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

Correspondence Address:
Shalu Gupta
Department of General Surgery J.L.N. Medical College & Hostiital, Ajmer
India

¤ Material and Method

¤ Observations

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. ^[1],[2] 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 ^[3] 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. ^[1] 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. ^[4] 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. ^[5]

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%. ^[7],[8] 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. ^[1] Kidney and urinary blad­der injuries were frequently asso­ciated with pelvic fractures and reteroperitoneal bleeding ^[2] 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. ^[9],[10] Retroperitoneal duodenal injury may be overlooked because of associated intra-abdominal injury. ^[11] 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

1.	Davis JJ, Cohn I, Nance, FC. Diag­nosis and management of blunt abdominal trauma. Ann Gurg 1976: 183;672-677.
2.	Olinde HDH. Non penetrating wounds of the abdomen: a report of 47 cases with review of the lite­rature, South Med J 1960:53;1270­1272.
3.	Drapanas T, McDonald J. Perito­neal tap in abdominal trauma. Sur­gery. 1961:50:742-744.
4.	Haynes CD, Gunn, CH, Martin JD. Colon injuries Arch Surg. 1968:96; 944-948.
5.	Fitzergald JF, Crawford ES, DeBakey MD. Surgical considera­tions of non-perentrating abdomi­nal injuries Am J Surg 1960:100; 22-29
6.	Allen RB, Curry GJ. Abdominal Trauma, Am J Surg 1957:93;398­404.
7.	Lucas CE, Walt AJ. Critical deci­sion in liver trauma : Experience based on 604 cases. Arch Suig 1070: 101;277-283.
8.	8 Schrock T. Blaisdell FW, Mathew­son C. Management of Blunt trauma to to liver and hepatic veins. Arch Surg 1968:96:698-704.
9.	Burrus GR, Howel JK, Jondan G. Traumatic duodenal injuries: An analysis of 86 cases. J Trauma 1961:1;96-99.
10.	Roman E, Silva, YJ, Lucas, C. Management of Blunt duodenal. in­jury Surg Gynecol Obstet 1971:132; 7-14.
11.	Cohn I, Hautrone HR, Frobese AS. Reteroperitoneal rupture of the duodenum in non-penetrating abdo­mial trauma. Am J Surg 1952:84; 293-301.

 
 

Tables

  [Table 1], [Table 2]

This article has been cited by 1 Comparison of incidence of injury of hollow viscus versus solid organs in blunt abdominal trauma Qureshi, K.H., Amin, M.A., Khan, I.H., Tahir, A.A. Medical Forum Monthly. 2005; 16(1): 32-38 [Pubmed] 2 Management of pediatric liver injuries: A 13-year experience at a pediatric trauma center Gross M, Lynch F, Canty T, et al. JOURNAL OF PEDIATRIC SURGERY. 1999; 34 (5): 811-816 [Pubmed]

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