Evaluation of abdominal trauma in adults

Diseases

Summary

Abdominal trauma is best categorized by mechanism as blunt or penetrating abdominal injury. The mechanism of injury dictates the diagnostic workup. As there is a broad spectrum of abdominal injuries, abdominal trauma patients are often difficult to assess. Confounding factors, such as associated extra-abdominal injuries or altered mental status (either from a head injury or intoxication) further complicate the evaluation.[1]

This topic includes the evaluation of abdominal trauma in adults only. For information on abdominal trauma in children, please see our topic "Evaluation of abdominal pain in children".

Anatomy

The surface anatomy of the abdomen extends from the nipple line to the groin crease anteriorly and from the tips of the scapulae to the gluteal skin crease posteriorly. The specific anatomic boundaries of the abdomen are the diaphragm, abdominal wall musculature, pelvic skeletal structures, and vertebral column. There are three basic regions of the abdomen: the peritoneal cavity with its intrathoracic component, the retroperitoneum, and the pelvic portion. As the diaphragm rises as high as the fourth intercostal space, trauma to the lower chest may involve abdominal organs.

Blunt abdominal trauma

Causes of blunt abdominal trauma include motor vehicle accidents (MVAs), motorcycle crashes (MCCs), pedestrian-automobile impacts, falls, and assaults. MVAs are the most common cause of blunt abdominal trauma, causing about 75% of such injuries. In the US in 2016 there were 37,461 fatalities from 34,439 fatal MVAs, 5286 fatalities related to MCCs, and 5987 pedestrians struck.[2] In about one third of these deaths, alcohol was involved.[3] Prevention strategies, such as campaigns against driving while intoxicated and encouragement of seatbelt use, have been shown to be effective in decreasing blunt abdominal trauma-related morbidity and mortality.[4] [5] [6] [7]

Blunt abdominal trauma can result in multiple different organ injuries. Complications of blunt abdominal trauma include peritonitis, hemorrhagic shock, and death. Common injuries are divided into two categories: solid organ (e.g., liver, spleen, pancreas, kidneys) and hollow organ (e.g., stomach, large and small bowel, gallbladder, urinary bladder) injuries. Solid organ injuries range from minor injuries such as small hemodynamically insignificant liver, spleen, or kidney lacerations to devastating injuries requiring immediate intervention. Bowel injuries require surgical repair to prevent peritonitis and septic shock.

Diaphragmatic injury accounts for <10% of blunt abdominal trauma, and splenic injury is more common with blunt than penetrating abdominal trauma.

Pancreatic injury is rare. In general it is more likely caused by blunt abdominal trauma, however penetrating injury may be more common in some countries (e.g., South Africa) and in the military.[8]

Penetrating abdominal trauma

Penetrating abdominal injuries occur when a foreign object pierces the skin. The most common penetrating injuries are gunshot wounds and stab wounds. In the US, penetrating trauma remains a major cause of morbidity and mortality, with 39,707 firearm-related deaths occurring in 2019.[9] Of these deaths, 38,850 were intentional (i.e., suicide or homicide) and 486 were accidental.[9] In European countries, firearm-related injuries are much less common.[10]

The external appearance of the penetrating wound does not determine the extent of internal injuries. It is important to define the trajectory of a penetrating wound and to consider all possible internal injuries. The mortality associated with penetrating abdominal trauma is related to the intra-abdominal organs injured, with refractory hemorrhagic shock being the leading cause of death.[11]

Stomach, small bowel, and colorectal injuries occur more frequently following penetrating abdominal trauma than following blunt trauma. The small bowel is the organ most commonly injured by penetrating abdominal trauma.

There is a high incidence of diaphragmatic injury in thoracoabdominal penetrating trauma.[12]

Citations

Key Articles

Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010 Mar;68(3):721-33.[Abstract][Full Text]
Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27(1):80.[Abstract][Full Text]
Diercks DB, Mehrotra A, Nazarian DJ, et al. Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med. 2011 Apr;57(4):387-404.[Abstract]
European Association of Urology. EAU guidelines on urological trauma. 2024 [internet publication].[Full Text]

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