Abdominal trauma is an injury to the abdomen

Abdomen

In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...

. It may be blunt

Blunt trauma

In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

 or penetrating

Penetrating trauma

Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...

 and may involve damage to the abdominal organs

Organ (anatomy)

In biology, an organ is a collection of tissues joined in structural unit to serve a common function. Usually there is a main tissue and sporadic tissues . The main tissue is the one that is unique for the specific organ. For example, main tissue in the heart is the myocardium, while sporadic are...

. Signs and symptoms include abdominal pain

Abdominal pain

Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...

, tenderness

Tenderness (medicine)

In medicine, tenderness is pain or discomfort when an affected area is touched.Rebound tenderness is an indication of peritonitis....

, rigidity, and bruising

Bruise

A bruise, also called a contusion, is a type of relatively minor hematoma of tissue in which capillaries and sometimes venules are damaged by trauma, allowing blood to seep into the surrounding interstitial tissues. Bruises can involve capillaries at the level of skin, subcutaneous tissue, muscle,...

 of the external abdomen. Abdominal trauma presents a risk of severe blood loss and infection

Infection

An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

. Diagnosis may involve ultrasonography, computed tomography

Computed tomography

X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...

, and peritoneal lavage, and treatment may involve surgery. Injury to the lower chest

Chest

The chest is a part of the anatomy of humans and various other animals. It is sometimes referred to as the thorax or the bosom.-Chest anatomy - Humans and other hominids:...

 may cause splenic or liver injuries.

Classification

Abdominal trauma is divided into blunt and penetrating types. While penetrating abdominal trauma (PAT) is usually diagnosed based on clinical signs, diagnosis of blunt abdominal trauma is more likely to be delayed or altogether missed because clinical signs are less obvious. Blunt injuries predominate in rural areas, while penetrating ones are more frequent in urban settings. Penetrating trauma is further subdivided into stab wounds

Stabbing

A stabbing is penetration with a sharp or pointed object at close range. Stab connotes purposeful action, as by an assassin or murderer, but it is also possible to accidentally stab oneself or others.Stabbing differs from slashing or cutting in that the motion of the object used in a stabbing...

 and gunshot wounds, which require different methods of treatment.

Signs and symptoms

People injured in motor vehicle collisions may present with a "seat belt

Seat belt

A seat belt or seatbelt, sometimes called a safety belt, is a safety harness designed to secure the occupant of a vehicle against harmful movement that may result from a collision or a sudden stop...

 sign," bruising on the abdomen along the site of the lap portion of the safety belt; this sign is associated with a high rate of injury to the abdominal organs. Seatbelts may also cause abrasions and hematomas; up to 30 percent of people with such signs have associated internal injuries. Early indications of abdominal trauma include nausea

Nausea

Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

, vomiting

Vomiting

Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...

, and fever

Fever

Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...

. Blood in the urine

Hematuria

In medicine, hematuria, or haematuria, is the presence of red blood cells in the urine. It may be idiopathic and/or benign, or it can be a sign that there is a kidney stone or a tumor in the urinary tract , ranging from trivial to lethal...

 is another sign. The injury may present with abdominal pain

Abdominal pain

Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...

, tenderness

Tenderness (medicine)

In medicine, tenderness is pain or discomfort when an affected area is touched.Rebound tenderness is an indication of peritonitis....

, distension

Distension

Distension generally refers to an enlargement or ballooning effect:* Gastric distension - bloating of the stomach when air is pumped into it, as in a medical procedure* Abdominal distension - abdominal bloating, a symptom of several medical conditions...

, or rigidity to the touch, and bowel sounds may be diminished or absent. Abdominal guarding

Abdominal guarding

Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed...

 is a tensing of the abdominal wall muscles to guard inflamed organs within the abdomen. Pneumoperitoneum

Pneumoperitoneum

Pneumoperitoneum is air or gas in the abdominal cavity. It is often seen on X-ray, but small amounts are often missed, and CT is nowadays regarded as a criterion standard in the assessment of a pneumoperitoneum. CT can visualize quantities as small as 5 cm³ of air or gas...

, air or gas in the abdominal cavity

Abdominal cavity

The abdominal cavity is the body cavity of the human body that holds the bulk of the viscera. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the thoracic diaphragm , and its oblique floor is the pelvic inlet...

, may be an indication of rupture of a hollow organ. In penetrating injuries, an evisceration

Disembowelment

Disembowelment is the removal of some or all of the organs of the gastrointestinal tract , usually through a horizontal incision made across the abdominal area. Disembowelment may result from an accident, but has also been used as a method of torture and execution...

 (protrusion of internal organs out of a wound) may be present.

Injuries associated with intra-abdominal trauma include rib fracture

Rib fracture

A rib fracture is a break or fracture in one or more of the bones making up the rib cage.The first rib is rarely fractured because of its protected position behind the clavicle . However, if it is broken serious damage can occur to the brachial plexus of nerves and the subclavian vessels...

s, vertebral fractures, pelvic fractures, and injuries to the abdominal wall.

Guidelines

Presentation Cause
Hemorrhage. Liver / spleen rupture
Hematuria. Kidney, bladder, ureter injury
Back pain. Injury to retroperitoneum
Peritonitis. Injury hollow viscus
Respiratory. Pneumothorax

Causes

Motor vehicle collisions are a common source of blunt abdominal trauma. Seat belts reduce the incidence of injuries such as head injury

Head injury

Head injury refers to trauma of the head. This may or may not include injury to the brain. However, the terms traumatic brain injury and head injury are often used interchangeably in medical literature....

 and chest injury, but present a threat to such abdominal organs as the pancreas

Pancreas

The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as a digestive organ, secreting pancreatic juice containing digestive enzymes that assist...

 and the intestines, which may be displaced or compressed against the spinal column. Children are especially vulnerable to abdominal injury from seat belts, because they have softer abdominal regions and seat belts were not designed to fit them. In children, bicycle

Bicycle

A bicycle, also known as a bike, pushbike or cycle, is a human-powered, pedal-driven, single-track vehicle, having two wheels attached to a frame, one behind the other. A person who rides a bicycle is called a cyclist, or bicyclist....

 mishaps are also a common cause of abdominal injury, especially when the abdomen is struck by the handlebars. Sports injuries can affect abdominal organs such as the spleen and kidneys. Falls and sports are also frequent mechanisms of abdominal injury in children. Abdominal injury may result from child abuse

Child abuse

Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...

 and is the second leading cause of child abuse-related death, after traumatic brain injury

Traumatic brain injury

Traumatic brain injury , also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism , or other features...

.

Gunshot wounds, which are higher energy than stab wounds, are usually more damaging than the latter. Gunshot wounds that penetrate the peritoneum

Peritoneum

The peritoneum is the serous membrane that forms the lining of the abdominal cavity or the coelom — it covers most of the intra-abdominal organs — in amniotes and some invertebrates...

 result in significant damage to major intra-abdominal structures in some 90 percent of cases.

Pathophysiology

Abdominal trauma can be life threatening because abdominal organs, especially those in the retroperitoneal space, can bleed profusely, and the space can hold a great deal of blood. Solid abdominal organs, such as the liver

Liver

The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...

 and kidney

Kidney

The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...

s, bleed profusely when cut or torn, as do major blood vessels such as the aorta

Aorta

The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...

 and vena cava

Venae cavae

The superior and inferior vena cava are collectively called the venae cavae. They are the veins that return deoxygenated blood from the body into the heart. They both empty into the right atrium....

. Hollow organs such as the stomach

Stomach

The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...

, while not as likely to result in shock from profuse bleeding, present a serious risk of infection, especially if such an injury is not treated promptly. Gastrointestinal organs such as the bowel can spill their contents into the abdominal cavity. Hemorrhage and systemic infection are the main causes of deaths that result from abdominal trauma.

One or more of the intra-abdominal organs may be injured in abdominal trauma. The characteristics of the injury are determined in part by which organ or organs are injured.

Liver

The liver

Liver

The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...

, the most vulnerable abdominal organ to blunt injury because of its size and location (in the upper right quadrant of the abdomen), is injured in about five percent of all people admitted to a hospital for trauma. The liver is also vulnerable to penetrating trauma. Liver injuries present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity. In children, the liver is the most commonly injured abdominal organ. The liver may be lacerated or contused, and a hematoma may develop. It may leak bile

Bile

Bile or gall is a bitter-tasting, dark green to yellowish brown fluid, produced by the liver of most vertebrates, that aids the process of digestion of lipids in the small intestine. In many species, bile is stored in the gallbladder and upon eating is discharged into the duodenum...

, usually without serious consequences. If severely injured, the liver may cause exsanguination

Exsanguination

Exsanguination is the fatal process of hypovolemia , to a degree sufficient enough to cause death. One does not have to lose literally all of one's blood to cause death...

 (bleeding to death), requiring emergency surgery

Surgery

Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 to stop the bleeding.

Spleen

Spleen is the most common damaged organ in blunt abdominal trauma. The spleen

Spleen

The spleen is an organ found in virtually all vertebrate animals with important roles in regard to red blood cells and the immune system. In humans, it is located in the left upper quadrant of the abdomen. It removes old red blood cells and holds a reserve of blood in case of hemorrhagic shock...

 is the second most commonly injured intra-abdominal organ in children. A laceration of the spleen may be associated with hematoma. Because of the spleen's ability to bleed profusely, a ruptured spleen

Ruptured spleen

Rupture of the capsule of the spleen, an organ in the upper left part of the abdomen, is a situation that requires immediate medical attention. The rupture of a normal spleen can be caused by trauma, such as a car accident.-Function In the Body:...

 can be life threatening, resulting in shock. However, unlike the liver, penetrating trauma to the spleen, pancreas and kidneys do not present as much of an immediate threat of shock unless they lacerate a major blood vessel supplying the organs, such as the renal artery

Renal artery

The renal arteries normally arise off the side of the abdominal aorta, immediately below the superior mesenteric artery, and supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle with the aorta....

. Fractures of the left lower ribs are associated with spleen lacerations in 20 percent of cases.

Pancreas

The pancreas may be injured in abdominal trauma, for example by laceration or contusion. Pancreatic injuries, most commonly caused by bicycle accidents (especially by impact with the handlebars) in children and vehicular accidents in adults, usually occur in isolation in children and accompanied by other injuries in adults. Indications that the pancreas is injured include enlargement and the presence of fluid around the pancreas.

Kidneys

The kidneys may also be injured; they are somewhat but not completely protected by the ribs. Kidney lacerations and contusions may also occur. Kidney injury, a common finding in children with blunt abdominal trauma, may be associated with bloody urine

Hematuria

In medicine, hematuria, or haematuria, is the presence of red blood cells in the urine. It may be idiopathic and/or benign, or it can be a sign that there is a kidney stone or a tumor in the urinary tract , ranging from trivial to lethal...

. Kidney lacerations may be associated with urinoma, leakage of urine into the abdomen. A shattered kidney is one with multiple lacerations and an associated fragmentation of the kidney tissue.

Bowel

The small intestine

Small intestine

The small intestine is the part of the gastrointestinal tract following the stomach and followed by the large intestine, and is where much of the digestion and absorption of food takes place. In invertebrates such as worms, the terms "gastrointestinal tract" and "large intestine" are often used to...

 takes up a large part of the abdomen ironically and is likely to be damaged in penetrating injury. The bowel may be perforated. Gas within the abdominal cavity seen on CT is understood to be a diagnostic sign of bowel perforation; however intra-abdominal air can also be caused by pneumothorax

Pneumothorax

Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...

 (air in the pleural cavity

Pleural cavity

In human anatomy, the pleural cavity is the potential space between the two pleura of the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally...

 outside the lung

Lung

The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...

s that has escaped from the respiratory system

Respiratory system

The respiratory system is the anatomical system of an organism that introduces respiratory gases to the interior and performs gas exchange. In humans and other mammals, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles...

) or pneumomediastinum

Pneumomediastinum

Pneumomediastinum is a condition in which air is present in the mediastinum...

 (air in the mediastinum

Mediastinum

The mediastinum is a non-delineated group of structures in the thorax, surrounded by loose connective tissue. It is the central compartment of the thoracic cavity...

, the center of the chest cavity). The injury may not be detected on CT. Bowel injury may be associated with complications such as infection, abscess

Abscess

An abscess is a collection of pus that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process or other foreign materials...

, bowel obstruction

Bowel obstruction

Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency...

, and the formation of a fistula

Fistula

In medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Locations:Fistulas can develop in various parts of the...

. Bowel perforation requires surgery.

Diagnosis

One study found that ten percent of polytrauma patients who had no clinical signs of abdominal injury did have evidence of the such injuries using radiological imaging

Radiology

Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body. Radiologists use an array of imaging technologies to diagnose or treat diseases...

. Diagnostic techniques used include CT scanning, ultrasound

Ultrasound

Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...

, and X-ray

X-ray

X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...

. X-ray can help determine the path of a penetrating object and locate any foreign matter left in the wound, but may not be helpful in blunt trauma. Diagnostic peritoneal lavage is a controversial technique but can be used to detect injury to abdominal organs: a catheter is placed in the peritoneal cavity

Peritoneal cavity

The peritoneal cavity is a potential space between the parietal peritoneum and visceral peritoneum, that is, the two membranes that separate the organs in the abdominal cavity from the abdominal wall...

, and if fluid is present, it is aspirated and examined for blood or evidence of organ rupture. If this does not reveal evidence of injury, sterile saline is infused into the cavity and evacuated and examined for blood or other material. While peritoneal lavage is an accurate way to test for bleeding, it carries a risk of injuring the abdominal organs, may be difficult to perform, and may lead to unnecessary surgery; thus it has largely been replaced by ultrasound in Europe and North America. Ultrasound can detect fluid such as blood or gastrointestinal contents in the abdominal cavity, and it is a noninvasive procedure

Medical procedure

A medical procedure is a course of action intended to achieve a result in the care of persons with health problems.A medical procedure with the intention of determining, measuring or diagnosing a patient condition or parameter is also called a medical test...

 and relatively safe for the patient. CT scanning is the preferred technique for people who are not at immediate risk of shock, but since ultrasound can be performed right in an emergency room, the latter is recommended for people who are not stable enough to move to CT scanning. However, people with abdominal trauma frequently need CT scans for other trauma (for example, head or chest CT); in these cases abdominal CT can be performed at the same time without wasting time in patient care. Diagnostic laparoscopy

Laparoscopy

Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...

 or exploratory laparotomy

Laparotomy

A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...

 may also be performed if other diagnostic methods do not yield conclusive results.

CT

CT is only able to detect 76% of hollow viscous injuries and patients who have negative scans must often be observed and rechecked if they deteriorate. However, CT has been demonstrated to be useful in screening patients with certain forms of abdominal trauma in order to avoid unnecessary laparotomies, which can significantly increase the cost and length of hospitalizations . A meta-analysis of CT use in penetrating abdominal traumas demonstrated sensitivity, specificity and accuracy >= 95%, with a PPV of 85% and an NPV of 98%. This suggests that CT is excellent for avoiding unnecessary laparotomies but must be augmented by other clinical criteria to determine the need for surgical exploration (23.37 positive likelihood ratio

Likelihood ratios in diagnostic testing

In evidence-based medicine, likelihood ratios are used for assessing the value of performing a diagnostic test. They use the sensitivity and specificity of the test to determine whether a test result usefully changes the probability that a condition exists.-Calculation:Two versions of the...

, 0.05 negative likelihood ratio).

Treatment

Initial treatment involves stabilizing the patient enough to ensure adequate airway, breathing, and circulation, and identifying other injuries. Surgery may be needed to repair injured organs. Surgical exploration is necessary for people with penetrating injuries and signs of peritonitis

Peritonitis

Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...

 or shock. Laparotomy

Laparotomy

A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...

 is often performed in blunt abdominal trauma, and is urgently required if an abdominal injury causes a large, potentially deadly bleed. However, intra-abdominal injuries are also frequently successfully treated nonoperatively. The use of CT scanning allows care providers to use less surgery because they can identify injuries that can be managed conservatively and rule out other injuries that would need surgery. Depending on the injuries, a patient may or may not need intensive care.

Prognosis

If abdominal injury is not diagnosed promptly, a worse outcome is associated. Delayed treatment is associated with an especially high morbidity

Disability

A disability may be physical, cognitive, mental, sensory, emotional, developmental or some combination of these.Many people would rather be referred to as a person with a disability instead of handicapped...

 and mortality

Mortality rate

Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...

if perforation of the gastrointestinal tract is involved.

Epidemiology

Most deaths resulting from abdominal trauma are preventable; abdominal trauma is one of the most common causes of preventable, trauma-related deaths.