Research Article - Archives of Clinical and Experimental Surgery (2022)
Detailed Study of Blunt Abdomen Trauma in a Tertiary Care Center
Sidduraj C Sajjan* and Saikalyan Gupta ASidduraj C Sajjan, Department of Surgery, Vydehi Institute Of Medical Sciences and Research Centre, Banglore, India, Email: dr.siddurajsajjan@gmail.com
Received: 10-Jan-2022, Manuscript No. EJMACES-22-51488; Editor assigned: 12-Jan-2022, Pre QC No. EJMACES-22-51488 (PQ); Reviewed: 26-Jan-2022, QC No. EJMACES-22-51488; Revised: 31-Jan-2022, Manuscript No. EJMACES-22-51488 (R); Published: 07-Feb-2022
Abstract
Background: Abdominal trauma is one of the most common causes among injuries caused mainly due to road traffic accidents. The rapid increase in motor vehicles and its aftermath has caused rapid increase in number of victims to blunt abdominal trauma. Motor vehicle accidents account for 75 to 80 % of blunt abdominal trauma.
Aim: To evaluate various clinical manifestations of blunt trauma abdomen, various available investigations for detection of intraperitoneal injuries, in particular, DPA, FAST and CT scan of abdomen, and to compare the efficacy of DPA and FAST in diagnosing hemoperitoneum.
Materials and methods: This was a prospective study where a total of 30 patients who underwent surgery for blunt abdomen trauma in Vydehi Institute of Medical Sciences and Research Centre, Bangalore were included. The clinical presentation, findings on investigation and operative findings were studied and the data was analyzed using appropriate statistical methods.
Results: Males (70%) were more commonly affected than females 930%), road traffic accidents were most common cause of injury. Splenic injuries (40%) were the most common injuries followed by small bowel (33.33%) and liver (33.33%). FAST was found to be more sensitive in detecting free fluid when compared to DPA. There were 2 deaths in the period of the study.
Conclusions: Blunt abdominal trauma is usually not obvious, hence often missed unless repeatedly looked for. Most deaths occur due to inadequate and delay in treatment of abdominal injuries. FAST is a rapid and effective method to detect free fluid in abdomen and organ injury.
Introduction
Abdominal trauma is one of the most common causes among injuries caused mainly due to road traffic accidents. The rapid increase in motor vehicles and its aftermath has caused rapid increase in number of victims to blunt abdominal trauma. Motor vehicle accidents account for 75 to 80 % of blunt abdominal trauma. Blunt injury of abdomen is also a result of fall from height, assault with blunt objects, sport injuries, industrial mishaps, bomb blast and fall from riding bicycle [1]. Blunt abdominal trauma is usually not obvious. Hence, often missed, unless, repeatedly looked for. Due to the inadequate treatment of the abdominal injuries, most of the cases are fatal [2,3]. The knowledge in the management of blunt abdominal trauma has progressively increasing due advances in diagnostics, in spite of this the morbidity and mortality remains at large. The reason for this could be due to the interval between trauma and hospitalization, delay in diagnosis, inadequate and lack of appropriate surgical treatment, post-operative complications and associated trauma especially to head, thorax and extremities.
Objectives of the study
1. To evaluate various clinical manifestations of blunt trauma abdomen.
2. To evaluate various available investigations for detection of intraperitoneal injuries, in particular, DPA, FAST and CT scan of abdomen.
3. To compare the efficacy of DPA and FAST in diagnosing hemoperitoneum.
Materials and Methods
Source of data
The patients for this study are those who presented at Vydehi Institute Of Medical Sciences And Research 2021 VOL 11, NO. 1, PAGE 01-07 Centre over the period of Nov 2012 to JUNE 2014 are included in the study. A minimum of 30 patients will be evaluated clinically and included in the study after applying the proper inclusion and exclusion criteria [4].
Methods of collection of data
Data was collected from the patients with their clinical history, clinical examination with appropriate investigations on those patients who were admitted. Post-operative follow up was done to note for complications. After initial resuscitation of the trauma victims, history was taken to document any associated medical problem. Routine blood and urine tests were carried out in all the patients. Documentation of patients, which included, identification, history, clinical findings, diagnostic test, operative findings, operative procedures, complications during the stay in the hospital and during subsequent follow-up period, were all recorded on a proforma specially prepared [5]. Demographic data collected included the age, sex, occupation and nature and time of accident leading to the injury.
After initial resuscitation and achieving, hemodynamic stability, all patients were subjected to careful examination, depending on the clinical findings; decision was taken for further investigations such as four-quadrant aspiration, x ray abdomen and ultrasound. The decision for further management depended on the outcome of the clinical examination and results of diagnostic tests. CT scan was done in 8 patients in our study. As most of our patients were from low socio economic group, and some patients were not hemodynamically stable to be shifted for CT scan [6]. Apart from routine investigations, abdomen x ray was done in all patients. All patients under went four-quadrant aspiration. An aspiration of blood, which did not clot, was taken as positive. When the aspirate clotted, the test was taken as negative. Ultrasound of abdomen was done in 29 cases [7].
Observations and Results
From Nov 2012 to June 2014, the total number of Blunt abdominal emergency operations was 32, out of which 2 patients were <18 yrs, hence not included in the study (Table 1). In this series, the majority of the patients belonged to 18-30 years age group, followed by 41-50 years age group (Table 2). In the 30 cases studied, 21 cases were males, and 9 females (Table 3). Road traffic accident was responsible for 86.66% of blunt abdominal trauma cases, while fall from heights accounted for 6.66% of cases and blow with blunt object was responsible for 6.66% of injuries [8].
Symptoms and signs
The following table shows the incidence of various symptoms and signs with which the 30 patients studied presented with Majority of the patients presented with abdominal pain (93.33%) and abdominal tenderness (80%) followed by tachycardia(70%) (Table 4 and 5).
| Age group (yrs) |
No.of patients |
Percentage (%) |
|---|---|---|
| 18-30 | 11 | 36.66% |
| 31-40 | 5 | 16.66% |
| 41-50 | 9 | 30% |
| 51-60 | 1 | 3.33% |
| 61-70 | 3 | 10% |
| 71-80 | 1 | 3.33% |
| Note: In this series, the majority of the patients belonged to 18-30 years age group, followed by 41-50 years age group. | ||
| Gender | No of patients | Percentage |
| Male | 21 | 70% |
| Female | 9 | 30% |
| Note: In the 30 cases studied, 21 cases were males, and 9 females. | ||
| Mode of injury | No.of cases | Percentage (%) |
| Road traffic accident | 26 | 86.66% |
| Fall from height | 2 | 6.66% |
| Blow to abdomen with blunt objects | 2 | 6.66% |
| Note: Road traffic accident was responsible for 86.66% of blunt abdominal trauma cases, while fall from heights accounted for 6.66% of cases and blow with blunt object was responsible for 6.66% of injuries. | ||
| Symptoms and signs | No of patients |
|---|---|
| Abdominal pain | 28 |
| Abdominal guarding and rigidity | 12 |
| Abdominal tenderness | 24 |
| Pallor | 06 |
| Pulse>90/min | 21 |
| BP<90 mm of Hg systolic | 04 |
| Free fluid | 05 |
| Note: Majority of the patients presented with abdominal pain (93.33%) and abdominal tenderness (80%) followed by tachycardia (70%). | |
| Hours | No of cases | Percentage |
| 0-5 | 15 | 50% |
| 6-10 | 11 | 36.66% |
| 11-15 | 02 | 6.66% |
| 16-20 | 01 | 3.33% |
| 21-25 | 01 | 3.33% |
| Note: Majority of patients (50%) were taken for surgery between 0-5 hours of latent period. | ||
Latent period
Latent period is the interval between the times of injury to the time of surgery. Majority of patients (50%) were taken for surgery between 0-5 hours of latent period (Table 6). Associated extra abdominal injuries were found in 6 cases. The common extra abdominal injuries were chest injuries including rib fractures, extremity fractures and head injuries [9].
| No of cases | Percentage | |
| Head | 2 | 6.66% |
| Thoracic | 1 | 3.33% |
| Orthopedic | 3 | 10% |
| Soft tissue | 3 | 10% |
| Combined | 3 | 10% |
| Note: Associated extra abdominal injuries were found in 6 cases. The common extra abdominal injuries were chest injuries including rib fractures, extremity fractures and head injuries. | ||
Investigations
Plain X ray abdomen: Plain X ray of abdomen was done in all cases. Gas under diaphragm was found in 10 cases. The following table shows the findings detected in X ray erect abdomen and their percentage (Table 7).
| Feature | No. of patients | Percentage |
|---|---|---|
| Gas under diaphragm (GUD) | 10 |
33.33% |
| No abnormality detected (NAD) | 20 | 66.66% |
Diagnostic peritoneal aspiration
Four quadrant aspirations were done in all patients, among which 8 cases. On laparotomy, they were found to have hemoperitoneum (Table 8).
| Result | No. of cases | Percentage |
|---|---|---|
| Positive | 8 | 26.66% |
Ct scan
CT scan was done in 8 cases, as most of the patients could not afford the investigation and few of them were not hemodynamically stable to undergo the scan [10].
Ultrasound examination
29 patients were subjected for ultrasound examination, out of which 16 patients had scan detected solid organ injuries for which they underwent laparotomy and found to have significant injuries. In 1 patient, scan did not detect any solid organ injury but patient had spleenic laceration on laparotomy [11]. 3 patients had scan detected normal solid organs with free fluid and found to have hollow viscus injury on laparotomy. Pattern of abdominal injuries detected by ultrasound in 29 patients is shown in the following table (Table 9).
| Organ injured | No. of patients | Percentage |
|---|---|---|
| Liver | 8 | 26.66% |
| Spleen | 6 | 20% |
| Combined | 1 | 3.33% |
| Free fluid without solid organ injury |
3 | 10% |
Operative findings
In the present series, small bowel was the most commonly involved organ. It was involved in 27% of cases, spleen in 25% and liver in 22% of cases (Table 10).
| Organ injured | No. of cases | Percentage |
|---|---|---|
| Small bowel | 10 | 33.33% |
Spleen |
12 | 40% |
Liver |
10 | 33.33% |
Stomach |
02 | 6.66% |
Mesentery |
11 | 36.66% |
| Retroperitoneum | 04 | 13.33% |
Gall bladder |
01 | 3.33% |
Pancreas |
02 | 6.66% |
Colon |
01 | 3.33% |
Operative procedures
The following table shows the various operative procedures carried out among the patients who underwent exploratory laparotomy. Liver injuries were usually graded as I and II [12]. Out of the 10 patients with liver injury, only 6 patients underwent hepatorraphy with abgel packing and rest of them were treated with abgelpacking alone. Out of 12 patients with splenic inju ry, 9 patients underwent splenectomy, 3 patients were treated by splenorrhaphy [13]. Bowel injuries were treated with 2 layered closure, only 1 patient who had complete transaction of duodenum proximal to ampulla of vater required gastro-jejunostomy. Mesenteric injuries were treated by simple suturing and ligating the bleeding points (Table 11).
| Procedure | No. of patients | Percentage |
|---|---|---|
| Closure of perforation | 9 | 30% |
| Splenectomy | 9 | 30% |
| Splenorrhaphy | 3 | 10% |
| Hepatorraphy | 6 | 20% |
| Repair of mesentery | 11 | 36.66% |
| Gastro-jejunostomy | 1 | 3.33% |
| Gastric perforation repair | 1 | 3.33% |
Morbidity
The mean duration of stay of patients in the hospital ranged from 11-20 days (15 days). The range varied from 2 days to 30 days. The following table shows the duration of stay of patients with blunt abdominal trauma including those who died (Table 12).
| No. of days | No. of patients | Percentage |
|---|---|---|
| 1-10 | 2 | 6.66% |
| 11-20 | 2 | 80% |
| 21-30 | 4 | 13.33% |
Mortality
2 patients died in the present study. One patient died on post-op day 5 due to pulmonary edema and sepsis, while the other person expired due to septicemia on post-op day 2. Therefore the mortality in the present study is 6.66% [14].
Discussion
Age incidence
The following table compares the incidence of blunt abdominal trauma in various age groups in the present series to that of the Davis et al. [16] (Table 13). It can be seen from the above table that the majority of patients belonged to less than 30 years of age group, followed by 41-50 years age group. In Davis et al study the majority of patients belonged to 21-30 years age group [15]. Therefore it can be concluded that the young and the productive age group people are the usual victims of blunt abdominal trauma (Table 14). From the above table, it can be seen that the males are the more common victims of blunt abdominal trauma, as males are involved in outdoor activities most of the times (Table 15).
| Age group (yrs) | Present series | Davis et al. |
|---|---|---|
| <30 | 36.66% | 43% |
| 31-40 | 16.66% | 15% |
| 41-50 | 30% | 13% |
| 51-60 | 3.33% | 6% |
| 61-70 | 10% | 3% |
| 71-80 | 3.33% | - |
| Note: It can be seen from the above table that the majority of patients belonged to less than 30 years of age group, followed by 41-50 years age group. In Davis et al study the majority of patients belonged to 21-30 years age group. Therefore it can be concluded that the young and the productive age group people are the usual victims of blunt abdominal trauma. | ||
| Gender | Present study | Fazili et al. |
|---|---|---|
| Male | 70% | 79.3% |
| Female | 30% | 20.7% |
| Note: From the above table, it can be seen that the males are the more common victims of blunt abdominal trauma, as males are involved in outdoor activities most of the times. | ||
| \ Mode of injury | Present study | Fazili et al. | Khanna et al. |
|---|---|---|---|
| Road traffic accident | 86.66% | 60.4% | 57% |
| Fall from height | 6.66% | 11.2% | 15% |
| Blow to abdomen with blunt objects |
6.66% | 17.4% | 33% |
| Note: The above table clearly depicts that the road traffic accident is the most common mode of injury. | |||
Mode of injury
The above table clearly depicts that the road traffic accident is the most common mode of injury.
Signs and symptoms
In the present study, abdominal pain was the most common presenting complaint accounting for 93.33% and abdominal tenderness was the most common sign accounting for 80% of cases. But the signs and symptoms in abdominal injuries are notoriously unreliable and are often masked by concomitant head injuries, chest injuries and pelvic fractures [17]. Significant injuries to the retroperitoneal structures may not manifest as signs and symptoms immediately and be totally missed even on abdominal x rays and DPA predisposing the patients to grave consequences of the missed injuries. In Davis et al. study, 43% of patients had no specific complaints and no signs or symptoms of intraabdominal injury when they first presented to the emergency room. But 44% of those patients eventually required exploratory laparotomy and 34% of patients had an intra-abdominal injury [18]. This emphasizes the importance of careful and continuing observation and repeated examination of individuals with blunt abdominal trauma (Table 16).
| Present study | Davis et al. | Khanna et al. | |
|---|---|---|---|
| Head | 6.66% | 9% | 12% |
| Thoracic | 3.33% | 27% | 24% |
| Orthopedic | 10% | 15% | 27% |
| Soft tissue | 10% | 12% | - |
| Combination | 10% | 6% | - |
| Note: Associated extra abdominal injuries were found in 12 cases. The common extra abdominal injuries were extremity fractures, head injuries and chest injuries including rib fractures. The above table shows the comparison of the present study incidences of associated injuries with other studies. | |||
Associated injuries
Associated extra abdominal injuries were found in 12 cases. The common extra abdominal injuries were extremity fractures, head injuries and chest injuries including rib fractures. The above table shows the comparison of the present study incidences of associated injuries with other studies [19].
Investigations
Plain X ray abdomen: Plain x ray of abdomen was done in all cases. Gas under diaphragm was found in 10 cases, which accounts for 33.33% cases in the present study. Davis et al reported that in their series, abdominal X ray was abnormal in 21% of cases; Pneumoperitoneum was detected in 6% of cases and dilated bowel loops in 6% of cases [20].
Four quadrant aspirations: In the present study all patients were subjected for four quadrant aspiration as against 44% in Davis et al study. 08 cases were found to be positive and 22 cases were negative. Out of these 22 cases, 7 cases were false negative in the present study [21]. Therefore the sensitivity of this investigation in the present study is 68.2%. Correct results (positive or negative), were determined by subsequent laparotomy, and were obtained in 86% of cases in Davis et al study [22].
Ultrasound examination: A total of 29 patients were subjected for ultrasound examination, out of which 15 patients had scan detected solid organ injuries for which they underwent laparotomy and found to have significant injuries [23]. Three patients’ had scan showed normal solid organs with free fluid and found to have hollow viscus injury at laparotomy [24]. Therefore ultrasound is more reliable in detecting solid organ injuries and free fluid in the abdomen. In Yoshi H et al study, the sensitivity of ultrasound in detecting injuries in blunt abdominal injury patients is about 94.6% (Table 17).
| Organ injured | Present series | Fazili et al. | Davis et al. | Cox et Al. |
Khanna et al. |
|---|---|---|---|---|---|
| Small bowel | 33.33% | 7.4% | 8% | 8% | 57% |
| Spleen | 40% | 2.8% | 25% | 46% | 26% |
| Liver | 33.33% | 4.2% | 16% | 33% | 37% |
| Stomach | 6.66% | 1.6% | 1% | 7% | |
| Mesentery | 36.66% | 6.3% | 4% | 10% | 47% |
| Colon | 3.33% | 4.7% | - | - | - |
| Retroperitoneum | 13.33% | 3.2% | - | - | - |
| Note: The above table compares the incidences of the organs involved in blunt abdominal trauma in the present study to that of the international series. As seen in these international series, spleen is the most common viscera injured even in the present series. GIT is the next commonly involved organ. Spleen was involved in 40% of cases, followed by small bowel (33.33%), and followed by liver (33.33%). | |||||
Organwise injury
The above table compares the incidences of the organs involved in blunt abdominal trauma in the present study to that of the international series [25]. As seen in these international series, spleen is the most common viscera injured even in the present series. GIT is the next commonly involved organ [26]. Spleen was involved in 40% of cases, followed by small bowel (33.33%), and followed by liver (33.33%) [27].
Operative procedures
In the present study closure of bowel perforation was done in 9 patients, repair of mesentery in 11 patients, splenectomy in 9 patients, splenorrhaphy in 3 patients, hepatorraphy in 6 patients and gastro-jejunostomy in 1 patient [28,29]. In this study closure of bowel perforation was done in 13 patients, colostomy in 2 patients, repair of mesentery in 9 patients, splenectomy in 4 patients, splenorrhaphy in 1 patient and hepatorraphy in 6 patients [30].
Conclusion
The perioperative and long-term outcomes of the liver- first and classical approaches are comparable. Selection of the surgical approach will depend on the characteristics of the primary colorectal tumor and liver metastases.
Acknowledgments
None
Funding
The authors received no funding for this work.
Conflict of Interest Statement
The authors declare that they have no conflict of interest.
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