Hollow Viscus Organ Trauma Andri Revisi 1

Hollow Viscus
Organ Trauma
Andriansyah Karnanda
Abdominal Trauma
Hollow Viscus
 Hollow : having a hole or empty space inside
 Viscus : an internal organ of the bod

Hollow viscus Injury
 Blunt injury to the intestines generally results from sudden

deceleration with subsequent tearing near a fixed point of
attachment, particularly if the patient’s seat belt was positioned
incorrectly.
 A transverse, linear ecchymosis on the abdominal wall (seat-belt
sign) or lumbar distraction fracture (i.e., Chance fracture) on x-
ray should alert clinicians to the possibility of intestinal injury.
 Although some patients have early abdominal pain and
tenderness, the diagnosis of hollow viscus injuries can be difficult
since they are not always associated with hemorrhage.
 Concomitant hollow viscus injury occurs in less
than 5% of patients initially diagnosed with
isolated solid organ injuries.
Outline
Background and Anatomy
Mechanism of Injury
Diagnosis
Treatment
Specific Organ treatment
Prognosis
Anatomy and Background
Anatomy of Abdomen
Advanced Trauma Life Support 10 th edition

Anatomy Hollow Viscus
Organ
 Esofagus
 Stomach
 Duodenum
 Jejunum
 Ileum
 Colon
 Rectum
 Bile duct
Background
rare : only 3-5% of abdominal blunt force trauma ->
Often underdiagnosed
It often happens in penetrating injury.
Diagnosis is difficult to confirm especially in blunt

trauma
Morbidity and high mortality
Systemic complications (sepsis) high - > 19.8%
Delays >24 hours in repair operations are related to a

mortality rate of 3 times
Feliciano DV, Mattox KL, Moore EE. eds. Trauma, 9e. McGraw Hill; 2020. Accessed October 11, 2021. https://accesssurgery.mhmedical.com/content.aspx?bookid=2952&sectionid=249115991
McStay C, Ringwelski A, Levy P, Legome E. Hollow viscus injury. J Emerg Med. 2009;37(3):293-299. doi:10.1016/j.jemermed.2009.03.017
Bège T, Brunet C, Berdah SV. Hollow viscus injury due to blunt trauma: A review. J Visc Surg. 2016;153(4 Suppl):61-68. doi:10.1016/j.jviscsurg.2016.04.007
Background
Incidents based on the type of organ involved
Jha NK, Yadav SK, Sharma R, et al. Characteristics of Hollow Viscus Injury following Blunt Abdominal Trauma; a Single Centre Experience from Eastern India. Bull Emerg Trauma. 2014;2(4):156-160.
Trauma mechanisms and clinical
spectrum
Mekanisme Trauma
Mechanisms of trauma
Blunt injury Penetrating injury
Direct impact,
Deceleration, increased Direct injury
intralument pressure
Clinical
spectrum
Intestinal Wall Trauma
• Serosa injury, seromuscular injury,

Full-thickness perforation, mural
hematome
Trauma mesenteric
• Bruising, hematome, bleeding
Clinical spectrum
Intestinal wall
trauma
(a) circular seromuscular tear;

(b) longitudinal seromuscular tear;
(c) jejunal tear in antimesenteric ;
(d) perforation of ileum and disinsersion of
mesenteika.
Clinical spectrum
Trauma
mesenteric
(a) mesenteric hematoma;

(b) mesosigmoid hematoma with mesophilic disinseration and sigmoid
seromusscular lasrasi;
(c) Infused mesenteric with intestinal ischemia;
(d) disinsersi ileal mesenteric root.
Grading mesenteric trauma
Bekker W, Hernandez MC, Zielinski MD, Kong VY, Laing GL, Bruce JL, Manchev V, Smith M, LClarke D, Defining an intra-operative blunt mesenteric injury grading system and its use as a tool for
surgical-decision making, Injury (2018), https://doi.org/10.1016/j.injury.2018.08.014
Diagnosis
Diagnosis (Blunt trauma)
History
Injury mechanism
Primary survey
ABCD
Secondary survey
Head to toe exam
Plain Radiographs
FAST, CT Scan
Class of Hemorrhage
Resuscitation
 Fluid resuscitation and avoidance of hypotension are important
principles in the initial management of patients with blunt trauma,
particularly those with traumatic brain injury. In penetrating trauma
with hemorrhage, delaying aggressive fluid resuscitation until
definitive control of hemorrhage is achieved may prevent additional
bleeding; a careful, balanced approach with frequent reevaluation is
required.
Hypotensive resuscitation
 Balancing the goal of organ perfusion and tissue oxygenation with the
avoidance of rebleeding by accepting a lower-than-normal blood
pressure has been termed “controlled resuscitation,” “balanced
resuscitation,” “hypotensive resuscitation,” and “permissive
hypotension.”
 Such a resuscitation strategy may be a bridge to, but is not a substitute
for, definitive surgical control of bleeding. Early resuscitation with
blood and blood products must be considered in patients with evidence
of class III and IV hemorrhage. Early administration of blood products
at a low ratio of packed red blood cells to plasma and platelets can
prevent the development of coagulopathy and thrombocytopenia.
Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled
resuscitation in patients with severe trauma. Journal of Intensive Care. 2017;5(1)
General concept of permissive hypotension
and damagecontrol resuscitation
a) The concept of «permissive hypotension» refers to managing

trauma patients by restricting the amount of fluid resuscitation
administered while maintaining blood pressure in the lower than
normal range if there is still active bleeding during the acute period
of injury .
b) «Permissive hypotension/ hypotensive resuscitation» implies the
titration and control of blood pressure. «Restricted/controlled»
resuscitation refers to the volume of fluid administered.
c) Neither permissive hypotension/hypotensive resuscitation nor
restricted/controlled resuscitation may be indicated in patients with
traumatic brain injury and/or spinal injury .
Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in

patients with severe trauma. Journal of Intensive Care. 2017;5(1)
Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and
restricted/controlled resuscitation in patients with severe trauma. Journal of Intensive Care. 2017;5(1)
Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation
in patients with severe trauma. Journal of Intensive Care. 2017;5(1)
Clinical trials for targeting and controlling
blood pressure
a) Patients were eligible for inclusion if they had

evidence of ongoing hemorrhage and had a SBP 100
mmHg or a low SBP of 70 mmHg until definitive
hemostasis was achieved. The mean age of the
subjects was 31, after excluding patients older than 55
b) Patients with preexisting diabetes mellitus or

coronary artery disease were also excluded
Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled

resuscitation in patients with severe trauma. Journal of Intensive Care. 2017;5(1)
DPL
DPL is another rapidly performed study to
identify hemorrhage
Note that DPL requires gastric and urinary

decompression for prevention of complications.
The technique is most useful in patients who Aspiration of gastrointestinal

are hemodynamically abnormal with blunt contents, vegetable fibers, or bile
abdominal trauma or in penetrating trauma through the lavage catheter
patients with multiple cavitary or apparent mandates laparotomy.
tangential trajectories.
Aspiration of 10 cc or more of
Relative contraindications to DPL include blood in hemodynamically
previous abdominal operations, morbid obesity, abnormal patients requires
advanced cirrhosis, and preexisting laparotomy
coagulopathy
FAST (Focused Abdominal Scan
for Trauma)
 FAST includes examination of four regions: the pericardial sac,
hepatorenal fossa, splenorenal fossa, and pelvis or pouch of
Douglas. After doing an initial scan, clinicians may perform a
single or multiple repeat scans to detect progressive
hemoperitoneum
Sensitivity 42% to 88%, and specificity 98-100%

Al-Sindy, R., Alaqrawy, H., Hafdullah, M. S., & Butts, C. (2018). Identification of Hollow Viscus Injury with FAST Examination in Kurdistan, Iraq. Case reports in emergency medicine, 2018, 5019415.
Advaned Trauma Life Support 10 th edition
CT Scan
Findings on CT Scan ->
intestinal wall trauma
 Intestinal wall discontinuity
(a)
 Colonic wall thickening (b)
 Increased or decreased
enhancement after IV
contrast©
CT Scan
Findings on CT Scan ->
mesenteric trauma
 Contrast extravasation (f)
 Vascular branch discontinuity
(g)
 Mesenteric fat infiltration
(blurring, hyperdense, horny
comb appearance) (d)
 Hematome (e)
 String of pearl appearanece (h)
The sensitivity and
specificity of findings on
CT Scan
In general it has a sensitivity of 83-94% and an accuracy of 84-99%,

a specificity of 97%
McStay C, Ringwelski A, Levy P, Legome E. Hollow viscus injury. J Emerg Med. 2009;37(3):293-299.
Diagnosis (penetrating injury)
History
Mekanisme injury AMPLE
Primary survey
ABCD
Secondary survey
Head to Toe : Penetration wound, Skin bruising, tenderness
Exploratory Laparotomy
TREATMENT
General management (blunt
trauma)
General management
(penetrating injury)
Exploratory Laparotomy
Treatment of organ specific
hollow viscus
Gastric trauma
Gastric trauma
Conservative
• Grade I with intramural hematoma
Laparoscopic evaluation and surgery
• Indications for laparoscopy are not clear, often miss diagnosis
Surgery
Grade I: observation or suture

Grade II/III: repair two layers
• Grade IV/V: reconstruction with gastroduodenostomy or
gastrojejunostomy
Small bowel trauma
Small bowel trauma
Grade I
• Observation or seromuscular suture
Grade II
• One or two layer debridement and repair
Grade III dan IV
• Resection and anastomosis
Small bowel trauma
Management of grades II and III

Small bowel trauma
Management of grade III and IV (resection and anastomosis)

Management algorithm for gastric
and small bowel trauma
Colon Trauma
Colon Trauma
non-destructive (grade I-II, and to a lesser

extent grade III)
• Primary repair
Destructive (mostly grade III, grade IV and V)
Resection and anastomosis

• Diversion (still controversial)
Treatment algorithms for colonic trauma
Rectal Trauma
Rectal trauma
Rectal trauma is treated the same as colonic trauma
In grade III-V (full thickness) -> surgical management according to

intraperitoneal or extraperitoneal location
Intraperitoneal -> primary repair
Extraperitoneal (2/3 upper) -> primary repair or resection and

anastomosis, proximal diversion in complex trauma
Extraperitoneal lower 1/3 -> primary repair or proximal diversion
Rectal trauma management
algorithm
Other therapies
Prophylactic antibiotics
• Antibiotics for both aerobic and anaerobic

bacteria
Tetanus prophylaxis
Prognosis
Laparotomy or Not?
 Management of patients with abdominal injury can be operative

(Laparotomy) or non operative.
 Generally, laparotomy is required in about 25% of abdominal
injuries
 Peritonitis, hemodynamic instability, evisceration and
impalement are most common indications for laparotomy
 Non-operative management is a standard protocol for
hemodynamically stable solid organ injuries with a failure rate of
2-3%.
Indications of Laparotomy in
Abdominal Trauma
 Blunt abdominal trauma with hypotension, with a positive FAST or clinical
evidence of intraperitoneal bleeding, or without another source of bleeding
 Hypotension with an abdominal wound that penetrates the anterior fascia
 Gunshot wounds that traverse the peritoneal cavity • Evisceration
 Bleeding from the stomach, rectum, or genitourinary tract following
penetrating trauma
 Peritonitis
 Free air, retroperitoneal air, or rupture of the hemidiaphragm
 Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract,
intraperitoneal bladder injury, renal pedicle injury, or severe visceral
parenchymal injury after blunt or penetrating trauma
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Hollow Viscus

 Hollow : having a hole or empty space inside

 Viscus : an internal organ of the bod

 Blunt injury to the intestines generally results from sudden

Specific Organ treatment

Advanced Trauma Life Support 10 th edition

It often happens in penetrating injury.

Diagnosis is difficult to confirm especially in blunt

Morbidity and high mortality

Systemic complications (sepsis) high - > 19.8%

Delays >24 hours in repair operations are related to a

Incidents based on the type of organ involved

Blunt injury Penetrating injury

• Serosa injury, seromuscular injury,

• Bruising, hematome, bleeding

(a) circular seromuscular tear;

(a) mesenteric hematoma;

a) The concept of «permissive hypotension» refers to managing

Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in

a) Patients were eligible for inclusion if they had

b) Patients with preexisting diabetes mellitus or

Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled

Note that DPL requires gastric and urinary

The technique is most useful in patients who Aspiration of gastrointestinal

Sensitivity 42% to 88%, and specificity 98-100%

In general it has a sensitivity of 83-94% and an accuracy of 84-99%,

• Grade I with intramural hematoma

Laparoscopic evaluation and surgery

• Indications for laparoscopy are not clear, often miss diagnosis

Grade I: observation or suture

• Observation or seromuscular suture

• One or two layer debridement and repair

Grade III dan IV

• Resection and anastomosis

Management of grades II and III

Management of grade III and IV (resection and anastomosis)

non-destructive (grade I-II, and to a lesser

Destructive (mostly grade III, grade IV and V)

Resection and anastomosis

In grade III-V (full thickness) -> surgical management according to

Intraperitoneal -> primary repair

Extraperitoneal (2/3 upper) -> primary repair or resection and

Extraperitoneal lower 1/3 -> primary repair or proximal diversion

• Antibiotics for both aerobic and anaerobic

 Management of patients with abdominal injury can be operative

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