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Abdominal Injuries Last Form
Abdominal Injuries Last Form
ABDOMINAL INJURIES
2023
ABDOMINAL INJURIES
Clinical features
Patients can generally be classified into the following categories based on their
physiological condition after initial resuscitation:
Haemodynamically ‘normal’ – investigation can be completed before
treatment is planned;
Haemodynamically ‘stable’ – investigation is more limited.
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Shock and signs of external trauma to the abdominal wall are present, but their
absence soon after injury does not rule out the possibility of intra-peritoneal damage
which will soon manifest itself in one of 2 ways:
1. Internal hemorrhage
May arise from injury to the solid viscera, mesenteries or main blood vessels.
It is characterized by progressive pallor, tachycardia and hypotension with
thirst, air hunger and subnormal temperature.
Locally, there may be tenderness and slight rigidity over the injured organ, and
shifting dullness may be elicited.
2. Peritonitis
Follows rupture of a hollow viscus. It manifests itself by pain, tenderness,
rigidity, fever and tachycardia. In late cases, there is:
a) Obliteration of liver dullness due to the escape of gas.
b) Shifting dullness in the flanks.
c) Dead silence on auscultation.
Diagnosis
1. Observation: Every patient with a history of abdominal injury should be kept
under close observation for at least 24 hours.
2. Exploratory laparotomy: is indicated whenever suspicious signs are present,
and should never be delayed until frank signs appear.
N.B.
Blood loss into the abdomen can be subtle and there may be no clear clinical
signs.
Blood is not an irritant and does not initially cause any abdominal pain.
Distension is subjective, and a drop in the blood pressure may be a very late
sign in a young fit patient.
Examination in unstable patients should take place either in the ED or in the
operating theatre if the patient is deteriorating rapidly.
Investigations
Laboratory investigations
• Blood picture and haematocrit value ↓↓ denote bleeding.
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Radiological investigations
Plain chest and abdominal X-rays (only in haemo-dynamically stable
patient).
o May reveal fracture of the lower ribs or pelvis or the presence of a foreign
body.
o Free air under the right copula of the diaphragm denotes injury of a hollow
organ.
CT abdominal scan;
o It should be only performed in a stable patient as it entails transfer of the
patient and it takes some time to be performed.
o It is very accurate in detecting injury to solid organs and in the grading and
follow-up of these injuries.
o It is also sensitive in the diagnosis of retroperitoneal and diaphragmatic
injuries.
o It is not sensitive in the detection of bowel injuries or acute pancreatic injuries
at an early stage.
Procedure
1. Abdomen is prepared with an antiseptic solution and is draped with sterile
towels.
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2. Local infiltration of local anesthetic, e.g. lidocaine in the midline below the
umbilicus.
3. 2-3 cm skin incision followed by a 1 cm incision in the linea alba.
4. Peritoneum is entered with a dialysis catheter.
5. The tube is directed posteriorly and inferiorly into the pelvis.
6. Aspiration with a syringe. Gross blood, or gross enteric contents are
indications for immediate laparotomy.
7. If neither blood nor enteric content is aspirated, I L of warm saline is instilled
into the peritoneum by intravenous tubing.
8. After waiting for 5 minutes the empty saline bottle is placed down in a
dependent position to siphon the lavage fluid out of the abdomen.
9. A sample of the fluid is sent to the laboratory. Positive findings that diagnose
an intra-abdominal surgery, and thus require laparotorny are:
a. Red blood cell count >1000000/ml.
b. White blood cell count> 500/rnl.
c. Elevated amylase.
10. The catheter is removed, and the linea alba and skin are closed with sutures.
Incision:
1. The abdomen is usually opened through a right paraumbilical paramedian
incision
2. On opening the abdomen, any escaping gas, turbid fluid or fecal matter
indicates injury to the hollow viscera while a large effusion of blood suggests
damage to the solid viscera, omentum or mesentery
3. However, a clean peritoneal cavity does not exclude injury to the bowel since
small perforations are readily sealed by prolapsed mucous membrane
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Exploration:
1. The solid viscera and mesentery are examined first so that any source of
bleeding can be located and dealt with.
2. The small intestine is systematically examined throughout its entire length,
commencing usually at the cecum. If a perforation is discovered, the affected
loop is held in a non-crushing clamp and retained at the surface until the rest
of the gut is examined since the discovery of further injuries may influence the
treatment to be adopted
3. The stomach and duodenum are inspected and palpated
4. The transverse colon is brought out for examination, and by suitable
retraction the other parts of the colon are examined in turn
Procedure:
The injured viscera are dealt with as follows:
1. Ruptured spleen is best treated by splenectomy !.
2. Liver: The tear is repaired with deeply placed mattress sutures of thick catgut
supported by a patch of falciform ligament or rectus sheath so that they do not
cut out. If the tear is inaccessible, the abdominal incision is extended into the
chest along the right eighth intercostal space to allow proper exposure and
debridement.
3. Mesentery: Small or radial tears are treated by simple suture, but large or
transverse tears interfering with the blood supply of the related segment of
bowel are treated by resection-anastomosis.
4. Small intestines: Small perforations can be closed by a single purse-string
suture, but large wounds are repaired transversely by 2 layers to avoid
narrowing of the lumen. Resection-anastomosis is indicated for multiple
injuries confined to one segment, for extensive laceration and bruising, and for
infarction of the gut due to laceration of the mesentery.
5. Colon: Perforations are best treated by exteriorization, the affected loop being
mobilized and brought to the surface as in the Paul-Mikulicz's operation for
carcinoma.
6. Stomach and duodenum: The tear is repaired transversely in two layers to
avoid narrowing of the lumen.
7. Pancreas: The tear is repaired accurately by silk sutures, and the lesser sac
should always be drained through the flank.
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The mortality of liver injury averages 15-20%. It gets worse if other major
organs are injured.
Aetiology
Liver trauma can be divided into those inflicted by accidents which may be blunt and
penetrating injuries;
• Blunt trauma occurs as a result of direct injury. The liver is a solid organ and
compressive forces can easily burst the liver substance. The liver is usually
compressed between the impacting object and the rib cage or vertebral
column. Most injuries are relatively minor and can be managed non-
operatively. Blunt injury produces contusion, laceration and avulsion injuries
to the liver, often in association with splenic, mesenteric or renal injury. Blunt
injuries are more common and have a higher mortality than penetrating
injuries.
• Penetrating trauma is relatively common. Penetrating injuries, such as stab and
gunshot wounds, are often associated with chest or pericardial involvement.
Not all penetrating wounds require operative management and may stop
bleeding spontaneously.
• Iatrogenic injury is increasing with the rising popularity of invasive
investigations as percutaneous liver biopsy, and percutaneous transhepatic
cholangiography (PTC).
• Spontaneous rupture of the liver is an extreme rarity that may happen with
eclampsia or hepatic tumours.
Pathology
Type of injury In increasing seriousness the following types can be seen
1. Small subcapsular haematoma.
2. Small superficial tear or tears.
3. Large subcapsular or intrahepatic haematoma.
4. Large deep tear or tears.
5. Shattered liver parenchyma which may include a whole lobe.
6. Vascular injury, the most difficult to control is that of the main hepatic veins
because of the difficult access.
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All lower chest and upper abdominal stab wounds should be suspect,
especially if considerable blood volume replacement has been
required.
Severe crushing injuries to the lower chest or upper abdomen often
combine rib fractures, haemothorax and damage to the spleen and/or
liver.
Abdominal pain, tenderness and rigidity due to parietal peritoneal
irritation, by blood.
Massive bleeding presents with the picture of haemorrhagic shock and
minor bleeding is discovered by diagnostic peritoneal lavage (DPL),
ultrasound or by CT scan, which are done in suspected cases. These
tests are particularly useful in the unconscious patient as it is difficult
to assess the abdomen.
The injury may also be discovered with systematic exploration during
laparotomy for penetrating abdominal trauma.
FAST can diagnose free intraperitoneal fluid. Patients with free
intraperitoneal fluid on FAST and haemodynamic instability, and
patients with a penetrating wound, will require a laparotomy and/or
thoracotomy once resuscitation is under way.
Owing to the opportunity for massive ongoing blood loss and the rapid
development of a coagulopathy, the patient should be directly
transferred to the operating theatre while blood products are obtained
and volume replacement is taking place. Patients who are
haemodynamically stable should have a contrast enhanced CT scan of
the chest and abdomen as the next step. This scan will demonstrate
evidence of parenchymal damage to the liver or spleen, as well as
associated traumatic injuries to their feeding vessels. Free fluid can
also be clearly established.
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Blunt trauma
Patients who are haemodynamically unstable will require an immediate
laparotomy.
For the patient who is haemodynamically stable, imaging by CT
should be performed to further evaluate the nature of the injury. It
provides information on the liver injury itself, as well as on injuries to
the adjoining major vascular and biliary structures.
Injury in which there is a suggestion of a vascular component should
be reimaged, as there is a significant risk of the development of
subsequent ischaemia, false aneurysms, arteriovenous fistulae or
haemobiliary fistula. It is advised that all patients should be rescanned
prior to discharge.
Most patients with blunt liver injury who are haemodynamically stable
can be managed conservatively. A subcapsular or intrahepatic
haematoma requires no specific intervention and should be allowed to
resolve spontaneously.
The indication for discontinuing conservative treatment is the
development of haemodynamic instability, evidence of ongoing blood
loss despite correction of any underlying coagulopathy and the
development of signs of generalised peritonitis.
Interventional radiology has an important role in management of liver
trauma and embolization to control hepatic artery bleeding is safe and
effective in a stable patient with no evidence of hollow viscus
perforation.
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3. Priority is for arrest of bleeding. As mentioned before, most small liver tears
are found to have stopped bleeding by the time the abdomen is explored, and
these tears deserve no treatment Preliminary control of brisk liver
haemorrhage can be attained by a combination of temporarily packing the
bleeding area, and the application of Pringle's manoeuvre to occlude the
hepatic artery and the portal vein for a period up to 20 minutes. The lessened
rate of bleeding allows the surgeon to visualize and ligate the injured vessels.
4. Whenever possible suturing liver tears should be avoided because it is likely to
leave a space for accumulation of haematoma that may infect or communicate
with intrahepatic bile ducts. It is, however, resorted to if control of bleeding
vessels is not possible in deep tears. Tying sutures over pedicled omentum
helps haemostasis. Deep transverse mattress sutures using special liver needles
is recommended.
5. A haematoma is explored to ligate the damaged vessels and ducts, and to
excise the dead tissues. It is then left open for drainage.
6. A lobe that is shattered beyond salvage is treated by excision of this lobe.
7. Firm packing of inaccessible and difficult bleeding areas, e.g., the hepatic
veins, may be the only method for temporary arrest of bleeding. The patient is
transferred to a specialized centre where the pack is removed in the operating
theatre, and the injury is dealt with.
8. Multiple intraperitoneal drains are always placed to guard against collections
of blood and bile. Prophylactic antibiotics are prescribed.
Consequences
1. The main danger of such injuries is bleeding, and this should be the main
concern of the surgeon. Most liver injuries stop bleeding by the time they are
explored, but some of them cause death from blood loss.
2. A liver haematoma sometimes communicates with a torn bile duct allowing
blood to trickle down the biliary passages to gastrointestinal tract producing
what is known 'haematobilia',
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control the fistula, the affected portion of the liver may require
resection.
Late vascular complications include hepatic artery aneurysm and
arteriovenous (precipitating acute heart failure if between the hepatic
artery and hepatic vein and acute portal hypertension if arterioportal)
or arteriobiliary fistulae (resulting in often painful haemobilia). These
are best treated non-surgically by a specialist hepatobiliary
interventional radiologist. The feeding vessel can be embolised
transarterially.
Hepatic failure may occur following extensive liver trauma. This will
usually reverse with conservative supportive treatment if the blood
supply and biliary drainage of the liver are intact.
Biliary injuries
Aetiology
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Injuries to the gallbladder and extrahepatic biliary tree are rare. They
occur as a result of blunt or penetrating abdominal trauma and occur
mainly from penetrating trauma, often in association with injuries to
other structures that lie in close proximity. The common bile duct can
be repaired over a T-tube or drained and referred to appropriate care as
part of damage control, or even ligated.
Pathology
Types of bile duct injuries include leaks, transection, occlusion
(ligation or stricture), or a combination. The majority of bile duct
injuries are iatrogenic, most commonly following laparoscopic
cholecystectomy, with an incidence of 0.3–2%.
Clinical Findings
Iatrogenic injury is perhaps more frequent than external trauma. The
physical signs are those of an acute abdomen. Patients usually present
with abdominal pain that may be diffused or localized. Nausea,
anorexia, and abdominal distention due to ileus may also be seen.
Clinically apparent ascites and bile peritonitis are less common. Fever
is often absent.
Investigations
Laboratory evaluation typically reveals leukocytosis and nonspecific
liver function test abnormalities. Initial imaging studies should involve
abdominal ultrasound to assess for fluid collections or abnormalities in
the biliary tree such as focal dilation, and radionuclide biliary
scintigraphy to assess for ongoing leakage. Technetium-99m–labeled
hepatoiminodiacetic acid derivative (HIDA) scanning is most accurate,
approaching 100%.
Treatment
Spleen
The spleen is one of the most frequently injured organ in the abdomen. Its injury is
particularly important because it causes severe blood loss. The spleen is normally
small, hidden by ribs and protected by the thick abdominal muscles.
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Aetiology
Predisposing factors
Splenic enlargement, which makes it more liable to trauma.
Diseases of the spleen like malaria which make it friable.
Types of trauma
Blunt abdominal trauma or trauma to lower thoracic cage. This is
usually a result of road traffic accidents and falling from a height.
Penetrating trauma of gunshots or stabbing.
Operative trauma occurs during an operation on adjacent viscera, e.g.,
during gastric or colonic surgery.
Spontaneous rupture of the spleen is rare.
Pathology
Splenic injury occurs from direct blunt trauma. Most isolated splenic injuries,
especially in children, can be managed non-operatively. However, in adults,
especially in the presence of other injury or physiological instability,
laparotomy should be considered. The spleen can be packed, repaired or
placed in a mesh bag. Splenectomy may be a safer option, especially in the
unstable patient with multiple potential sites of bleeding. In certain situations,
selective angioembolisation of the spleen can play a role.
Types of splenic injury
Subcapsular haematoma.
Small superficial tears, single or multiple.
Deep tear, single or multiple.
Avulsion of a pole of the spleen.
Complete pulping of the spleen.
Injury of the vascular pedicle, i.e., avulsion or thrombosis of the vessel.
Clinical picture
There are 3 clinical presentations of rupture of the spleen.
Fatal type
The tear is deep or the pedicle is ruptured and haemorrhage is so massive that rapid
death occurs. Small vessels in the spleen and sinusoidal, i.e., they lack muscle coats
and hence do not constrict to stop bleeding.
Classical rupture
This is the commonest presentation.
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Delayed rupture
The initial shock is followed by a long lucid interval, which may
extend to a few days or weeks, after which the patient presents with the
picture of internal haemorrhage.
This delay of clinical presentation may be due to
A subcapsular haematoma or a perisplenic one that is enclosed in
omentum enlarges gradually and ruptures.
A clot stops bleeding but is later dislodged when the blood pressure
rises, or is digested by enzymes from an injured pancreas.
Investigations
Repeated blood picture. Declining haemoglobin and haematocrit
denote
haemorrhage.
Ultrasound or CT scan of the abdomen have diagnostic accuracy of
more than 90%. Serial examinations monitor the haematoma size.
Plain x-ray of the abdomen is a poor diagnostic substitute but may
reveal fracture of one or more of lower ribs.
Peritoneal lavage reveals blood.
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Treatment
Until the 1970s, splenectomy was considered mandatory for all splenic
injuries. Recognition of the immune function of the spleen refocused
efforts on operative splenic salvage in the 1980s.
After demonstrated success in pediatric patients, nonoperative
management has become the preferred means of splenic salvage for all
patients. The identification of contrast extravasation as a risk factor for
failure of nonoperative management led to liberal use of
angioembolization.
The role of selective angioembolization (SAE) continues to be defined,
but appears warranted in high grade injuries, particularly those with
contrast blush.
It is clear, however, that up to 15% to 20% of patients with splenic
trauma warrant early splenectomy and that failure of nonoperative
management often represents inappropriate patient selection.
Indications for early intervention in adults include initiation of blood transfusion within the first
12 hours and hemodynamic instability. Unlike hepatic injuries, which usually rebleed
within 48 hours, delayed hemorrhage or rupture of the spleen can occur up to weeks
after injury.
Splenic injuries are managed operatively by splenectomy, partial splenectomy,
or splenic repair (splenorrhaphy), based on the extent of the injury and the
physiologic condition of the patient. Splenectomy is indicated for significant
hilar injuries, pulverized splenic parenchyma, or any >grade II injury in a
patient with coagulopathy or multiple life-threatening injuries.
Autotransplantation of splenic implants to achieve partial immunocompetence
in younger patients who do not have an associated enteric injury. Partial
splenectomy can be employed in patients in whom only the superior or inferior
pole has been injured. During splenorrhaphy hemostasis is achieved by topical
methods (electrocautery; argon beam coagulation; application of thrombin-
soaked gelatin foam sponges, fibrin glue, or BioGlue), envelopment of the
injured spleen in absorbable mesh, and pledgeted suture repair.
Sequences:
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Plain film radiographs and ultrasound are of limited value. Loss of a distinct
psoas margin or a halo of air surrounding the kidney or psoas may suggest a
retroperitoneal process, however, this is nonspecific.
Abdominal CT scan is useful and may have findings specific to the diagnosis,
including pancreatic transaction, local hematoma, fluid separating the pancreas
and splenic vein, pancreatic enlargement, and increased attenuation of the
peripancreatic fat. In lieu of these, the admission CT scan may hold signs
suggestive of pancreatic injury, including fluid in the lesser sac, thickening of
the anterior renal fascia, and associated injuries to local structures. CT rarely
shows ductal disruption. Sensitivity for detecting pancreatic injury by initial
CT scan alone ranges from 60% to 80%, and repeat imaging may be helpful.
Specificity is high, ranging from 80% to 100%, although CT tends to
underestimate degree of injury.
MRCP is particularly good at identifying pancreatic injury and at
characterizing type and degree of damage. MRCP is excellent at clarifying
ductal status and at detailing parenchymal injury. ERCP is no longer
considered a first-line diagnostic option, due to its invasive nature.
Support with intravenous fluids and a ‘nil by mouth’ regimen should be
instituted while these investigations are performed. There is no need to rush to
a laparotomy if the patient is haemodynamically stable, without peritonitis.
Principles of management
It is preferable to manage conservatively at first, investigate and, once the
extent of the damage has been ascertained, undertake appropriate action.
ERCP with pancreatic stent placement is a less invasive alternative that should
be considered when emergent surgery is not required and when disruption is
suggested on imaging. Outcomes appear to vary depending on the degree and
location of disruption. Partial disruptions in the body and head appear to have
the highest response rates. Additionally, placement of a stent that bridges the
disruption is associated with better outcomes. Patients with complete duct
disruptions do not fare as well with endoscopic treatment; however, data are
limited.
Operation is indicated if there is disruption of the main pancreatic duct; in
almost all other cases, the patient will recover with conservative management.
Assessment of pancreatic damage and duct disruption at the time of surgery
can be difficult, because the bruising associated with the retroperitoneal
damage prevents clear visualization of the pancreas. A patient and thorough
examination of the gland should be carried out. Haemostasis and closed
drainage is adequate for minor parenchymal injuries.
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Stomach
Most stomach injuries are caused by penetrating trauma.
Blood presence is diagnostic if found in the nasogastric tube, in the absence of
bleeding from other sources.
Surgical repair is required but great care must be taken to examine the
stomach fully, as an injury to the front of the stomach can be expected to have
an ‘exit’ wound elsewhere on the organ.
Duodenum
Duodenal injury is frequently associated with injuries to the adjoining
pancreas. Like the pancreas, the duodenum lies retroperitoneally and so
injuries are hidden, discovered late or at laparotomy performed for other
reasons. CT is the diagnostic modality of choice. The only sign may be gas or
a fluid collection in the periduodenal tissue, and leakage of oral contrast,
administration of which may improve accuracy of diagnosis.
Smaller injuries can be repaired primarily. The first, third and fourth parts of
the duodenum behave like small bowel, and can be repaired in the same
fashion. The second part of the duodenum is fixed to the head of the pancreas
with a common blood supply, and may have a poorer blood supply compared
to the remainder. Major trauma, especially if the head of the pancreas is
simultaneously injured, should be treated as part of a damage control
procedure and be referred for definitive care.
Small bowel
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Colon
Injuries to the colon from blunt injury are relatively infrequent, and are more
frequently a penetrating injury. If relatively little contamination is present and
the viability is satisfactory, such wounds can be repaired primarily. If,
however, there is extensive contamination, the patient is physiologically
unstable or the bowel is of doubtful viability, then the bowel can be closed off
(‘clip and drop’). A defunctioning colostomy can be formed later or the bowel
reanastomosed once the patient is stable.
Rectum
Only 5% of colon injuries involve the rectum. These are generally from a
penetrating injury, although occasionally the rectum may be damaged
following fracture of the pelvis.
Digital rectal examination will reveal the presence of blood, which is evidence
of intestinal or rectal injury. These injuries are often associated with bladder
and proximal urethral injury.
With intraperitoneal injuries, the rectum is managed as for colonic injuries.
Full-thickness extraperitoneal rectal injuries should be managed with either a
diverting end-colostomy and closure of the distal end (Hartmann’s procedure)
or a loop colostomy. Presacral drainage is no longer used.
Mesenteric injury
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