Injury, Int. J.

Care Injured (2004) 35, 228—231

Gastric rupture from blunt abdominal trauma

Eva Esther Tejerina Álvarez*, Mar½´a Soledad Holanda,
Francisco López-Espadas, Maria José Dominguez,
Elsa Ots, Jenaro D½´az-Regañón

Unit of Multisystem Trauma, Department of Intensive Medicine, Marqués de Valdecilla

Hospital of Santander, Cantabria, Spain
Accepted 25 May 2003

KEYWORDS
Gastric rupture; Blunt
abdominal trauma;
Road traffic accidents;
Seat belts; Deceleration;
Splenic injury;
Thoracic trauma;
Intraabdominal sepsis;
Chemical peritonitis;
Peritoneal lavage
Summary Gastric rupture following blunt abdominal trauma is rare, with a reported
incidence of 0.02—1.7%. Road traffic accidents remain the most frequent cause. The
factors most often implicated in the genesis of this entity are: a history of a recent
meal, trauma to the left side of the body and an inappropriate use of seat belts. Splenic
injury is generally the most common associated injury. The high morbidity and mortality
are directly related to the number of associated injuries, delays in diagnosis and the
development of intraabdominal sepsis. We performed a retrospective study of 1300
patients with blunt trauma to the abdomen from 1973 to 2001. Seven patients sustained
a gastric rupture (five men and two women). The following associated characteristics
were analysed: mechanism of injury, clinical presentation, possible associated injuries
and postoperative complications, diagnosis methods and surgical treatment. We found
an incidence of gastric rupture of 0.5%. We emphasise an early diagnosis and aggressive
surgical treatment as a key to decreasing the mortality and morbidity from this injury.
However, in our series, the morbidity is mainly from associated injuries.
ß 2003 Elsevier Ltd. All rights reserved.

Introduction generally the most common associated injury, fol-

Gastric rupture following blunt abdominal trauma is
rare and large series in the literature report an
incidence between 0.02 and 1.7%.4—7,10,18,19,21,22
Road traffic accidents remain the most frequent
cause of gastric rupture and count for about 75%
of patients. The mortality rate ranges from 0 to
66%,4—7,10,18,19,21,22 and is mostly related to asso-
ciated injuries. The factors most often implicated
are: a history of a full stomach or recent meal,
trauma to the left side of the body and an
inappropriate use of seat belts. Splenic injury is
*Corresponding author. Tel.: þ34-91-5399504/658-771710;
fax: þ34-942-203543.
E-mail address: evateje@latinmail.com
(E.E. Tejerina Álvarez).
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0020-1383(03)00212-2
lowed by thoracic injury. The high morbidity and
mortality associated with gastric rupture are
directly related to associated injuries, delays in
diagnosis and intraabdominal septic complications.
The purpose of this study was to review cases of
gastric rupture from blunt abdominal trauma and its
associated characteristics in our intensive care unit.
Material and methods
We performed a retrospective study of 1300
patients with blunt trauma to the abdomen treated
in our intensive care unit during the 28-year period
from 1973 to 2001. Seven patients sustained a
gastric rupture (five men and two women). The
Gastric rupture from blunt abdominal trauma 229

following associated characteristics were analysed:
mechanism of injury, clinical presentation, possible
associated injuries and postoperative complica-
tions, diagnosis methods and surgical treatment.
Results
The clinical results of the patients with gastric
rupture are shown in Table 1.
Discussion
We found seven gastric ruptures in 1300 patients
with blunt abdominal trauma, an incidence of 0.5%
and with a mortality rate of 0%. Several published
series4—7,10,18,19,21,22 reported an incidence of gas-
tric rupture from blunt abdominal injury of 0.02—
1.7%, as shown in Table 2.
Although some authors18 find that the incidence
is higher in childhood, other reported series4,21
failed to demonstrate such a correlation with
age. Males were injured four times as frequently
as females.22 In our series, males were involved in
five cases of gastric rupture (71.4%), with an aver-
age age of 31.8 years (range from 9 to 46 years).
Road traffic accidents are the most important
cause of gastric rupture from blunt trauma and were
involved in nearly 75% of the patients.4 In the pre-
sent series, motor vehicle accidents account for
85.7% of gastric tears. Other causes are falls, direct
violence, cardiopulmonary resuscitation and seat-
belt injury.4,8,21. Most reported abdominal injuries
are associated with lap belts, often worn incor-
rectly.1,2,8,12,15 Spontaneous rupture may also occur
in adults after an excessive consumption of food,
liquids or sodium bicarbonate.22
The stomach is a thick-wall, muscular and capa-
cious organ with a relatively protected anatomical
position and a high degree of mobility, so it is
relatively resistant to a blunt injury, particularly
when empty. However, when the stomach is dis-
tended, as by a recent meal, blunt trauma to the

Table 1 Clinical results of the patients with gastric rupture

Characteristics Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7
Age (years) 7 24 33 29 48 42 40
Sex Female Male Male Male Female Male Male
APACHE II Unknown 14 9 11 8 Unknown 9
Mechanism Beaten by Motor Motor Motor Motor Motor Motor
of injury the snout vehicle vehicle vehicle vehicle vehicle vehicle
of a cow accident accident accident accident accident accident
Symptoms Peritoneal Peritoneal Abdominal Abdominal Abdominal Peritoneal Thoracic
and signs irritation irritation pain pain pain irritation pain
Hematoma Hematoma Shock Haematemesis Thoracic pain Shock Haematemes
in left in left lower Shock Peritoneal
hemithorax quadrant irritation
Shock
Diagnostic Pneumoperitoneum Laparotomy PL: positive PL: positive PL: positive PL: positive Pneumoperitoneum
method on X-ray on X-ray
Associated No Spleen Pancreatic Spleen Spleen Serosal tear of the Bilateral lung
injuries laceration section rupture laceration transverse colon contusion
Left Liver Right Right femur Left Myocardial
hemidiaphragm laceration retroperitoneal and fibula retroperioneal contusion
rupture hematoma fractures hematoma Left rib fracture
Pelvis fracture Retroperitoneal Pelvis fracture Head injury
Myocardial hematoma Head injury Head injury
contusion

Site of rupture Lesser curvature Anterior wall Posterior wall Posterior wall Anterior wall Anterior and Anterior wall
and other Gastric contents Gastric contents posterior wall
findings in abdominal in abdominal Gastric contents
cavity cavity in abdominal
cavity

Complications Left pleural Left pleurisy Intraabdominal No No Intraabdominal No

effusion abscess abscess
Mortality No No No No No No No
Length of stay 6 9 17 6 2 25 7
in UCI (days)
Length of stay in 10 13 96 19 8 56 13
hospital (days)

PL: peritoneal lavage; MOSF: multiorgan system failure.

230
Table 2 Incidence and mortality of gastric rupture in several published series
Series Incidence of hollow
visceral injury (%)
Yajko and associates (1930—1975): 37 cases 11—18
Semel and Frittelli (1975—1981): 17 cases
Courcy and associates (8 years): 6 cases 2.9
Bransting and Morton (10 years): 6 cases
upper abdomen can lead to an increase in intragas-
tric pressure sufficient to cause rupture. According
to Law of Laplace (P ¼ T=R), wall tension is highest
in the parts of the stomach with the greatest radius
of curvature, such as the anterior wall and greater
curvature, predisposing them to rupture.4,9,22 In
several published series,4,13,18,19,21,22 a history of
recent meal prior to gastric rupture is significantly
related to this injury, with a reported incidence of
27—76%. In our series, only one patient had a full
stomach just before injury.
Tearing by deceleration has been postulated as
other possible mechanism of injury to the stomach
directly related with the use of lap-belt-style
restraining devices.2,8,9,12,14,15 Lap belts are
designed to be worn at or below the level of the
anterior superior iliac spines, but have a tendency
to ride up over the abdomen. In this location, a
sudden deceleration may cause abrupt and direct
compression of the stomach between the seat belt,
the posterior abdominal wall and the rigid spinal
column. Lap and shoulder types of belts spread the
deceleration over a larger area so that they should
be less likely than lap belts to cause direct compres-
sion injury of abdominal viscera.2,8,14 Deceleration
also generates shearing forces at the relatively fixed
junction of the pylorus and duodenum and a simul-
taneous rapid forward motion of the stomach. This
last mechanism appears more likely in the case of
gastric rupture associated with the lap belt. In our
study, only one patient was wearing seat belt when
he was involved in a road traffic accident, but it is
unknown what type of seat belt he used.
The majority of patients either present in shock or
with signs and symptoms of an acute abdomen,
mainly as a result of the chemical peritonitis induced
by the spillage of gastric acid.3,4,11,13,18,20—22 In the
present series, the most frequent clinical findings
were abdominal pain, peritoneal irritation and shock
(42.8%), followed by haematemesis and haematoma
on the left side of the body (28.5%), which seem to be
more specifically related to gastric rupture. Subcu-
taneous emphysema may appear via the mediasti-
num when rupture occurs near the cardioesphageal
area.13,18,22 Free intraperitoneal air on abdomen and
chest films may be absent in 29.4—83.3% of the
E.E. Tejerina Álvarez et al.
Incidence of gastric Mortality (%)
rupture (%)
0.9—1.7 47
12
0.4 0
50
cases.4,6,18,19,21 This may be attributable to the fact
that most trauma patients have radiographic exam-
inations performed while in the supine position. In
our series, there was a pneumoperitoneum in five
cases (71.4%). Aspiration of a dark peritoneal lavage
fluid by the action of gastric acid on haemoglobin, a
turbid fluid as well as the presence of bile or amylase,
may suggest gastric rupture.4,16,17,21 In the present
study, haemoperitoneum was suspected on clinical
findings and was confirmed with a positive peritoneal
lavage in four patients. Ultrasound may be useful to
detect abdominal fluid. CT-scan is especially valu-
able if the diagnosis of gastric rupture is delayed.1,20
Splenic injury is generally the most common
associated injury, followed by significant thoracic
injuries, mainly to the left side of the body.4,16,17,21
Thoracic trauma is a major contributing factor
towards substantial morbidity and mortality asso-
ciated with gastric rupture.4,9 Splenic injury was
present in three of our patients (42.8%), trauma to
left side of the body was present in four patients
(57.1%) and thoracic trauma to this same side in two
patients (28.5%).
The majority of complications are directly
related to the massive intraperitoneal contamina-
tion with undigested food and gastric acid, causing a
chemical peritonitis.6,16,20 Delay in diagnosis
increases the period of peritoneal contamination
and adds to the mortality.1,21 The most common
complication is intraabdominal abscess formation.
Gastric fistulae may also occur. Two of our patients
(28.5%) developed intraabdominal abscesses.
Blunt gastric rupture can occur in any portion of
the stomach. It usually occurs as a single lesion,
which is commonly debrided and repaired by pri-
mary closure. It is unusual a gastric rupture with
extensive damage requiring partial gastrect-
omy.16,19 The anterior gastric wall is most often
involved, reported to be 40% in the reviewed lit-
erature,4,6,18,22 as shown in Table 3, followed by
greater curve (23%), lesser curve (15%), and poster-
ior wall (15%). However, the greater curvature is the
site most often affected in the paediatric age
group.21 The injury occurs more commonly on a full
stomach leading to peritoneal contamination with
solid food particles as had occurred in three of our
Gastric rupture from blunt abdominal trauma
Table 3 Site of gastric rupture in several published series
Series
Yajko and associates (1930—1975): 37 cases
Semel and Frittelli (1975—1981): 17 cases
Courcy and associates (8 years): 6 cases
Brunsting and Morton (10 years): 6 cases
cases. In the present series, the anterior wall of the
stomach is the most common site of rupture (57.1%),
Similar to other reviewed series, followed by poster-
ior wall (42.8%) and lesser curve (14.2%). In our
series, greater curve was not affected in any patient.
Some authors recommend adequate debridement
of the margins of the laceration and a postoperative
gastric decompression is also advised. It is also
important to inspect the entire surface of the sto-
mach, even the posterior surface. To prevent the
occurrence of an intraabdominal abscess the abdom-
inal cavity needs an extensive mechanical irrigation
with large amount of a diluted solution of beta-
dine.6,20. In the case of abscess formation, an aggres-
sive approach of early reoperation and drainage is
emphasised.4,19,20 Primary gastric closure was per-
formed in all seven patients in our series.
The mortality associated with gastric rupture has
been reported to range from 0 to 66%.4—7,10,18,19,21,22
It is mostly related to associated injuries, septic
complications and, less frequently, to fatal shock.4,17
In the present study, we observed a mortality rate
of 0%.
Conclusions
We report an incidence of gastric rupture of 0.5% of
all blunt trauma admissions in our unit, similar to
that seen in the reviewed literature. We agree with
other authors in emphasising an early diagnosis and
aggressive surgical treatment as a key to decreasing
the mortality and morbidity from this injury. How-
ever, in our series, the morbidity is mainly from
associated injuries.
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Anterior Greater Lesser Posterior
wall (%) curvature (%) curvature (%) wall (%)
26 16 32 11
53 29 6 12
33 33 0 33
60 20 0 20
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