ABDOMINAL EMERGENCIES

KITYAMUWESI RICHARD

PRESENTATION OUTLINE
Introduction
Definition
Common causes of acute abdominal
emergences in adults
Common signs and symptoms
Types of abdominal pain
Differential diagnosis by location
Principles of managing the acute abdomen
Discussion of the different conditions

INTRODUCTION
Acute surgical emergencies constitute 50%
of all the general surgical admissions.
Half of these have abdominal symptoms
predominantly pain.
In half of the patients with abdominal
symptoms the presenting conditions resolve
without operation, while the rest undergo
emergency surgery.

ACUTE ABDOMEN - DEFINITION

Acute abdomen is a pathophysiologic process
involving the abdominal cavity and its viscera,
associated with pain that has a sudden onset
and may require surgical intervention.

CAUSES OF ACUTE ABDOMEN COULD BE DUE TO:-

Inflammation
Obstruction
Haemorrhage
Metabolic
Perforation
Infection

COMMON CAUSES OF ACUTE ABDOMINAL

EMERGENCES IN ADULTS

Non specific abdominal pain

Acute appendicitis
Acute biliary disorders e.g. Biliary colic, cholecystitis
Acute pancreatitis
Acute manifestations of peptic ulcer disease e.g. Pain, perforation, haemorrhage
Acute diverticulitis
Strangulated hernias
Intestinal obstruction
Colorectal carcinoma with large gut obstruction, perforation
Intussusceptions,
Constipation
Sigmoid volvulus
Urinary tract infections, ureteric colic,
Acute urinary retention
Ruptured abdominal aortic aneurysm
Mesenteric ischemia
Abdominal trauma with bleeding or perforation
Gynecological emergencies- ruptured ectopic, acute salpingitis, torsion or bleeding ovarian cyst.
Sickle cell crisis, acute intermittent porphyria, tabes dorsalis
peritonitis

NON-SURGICAL EMERGENCIES ASSOCIATED

WITH ACUTE ABDOMINAL PAIN

Mesenteric Adenitis
Acute Enteric Infections
Acute Enteric Poisonings
Inflammatory Bowel Disease
Pancreatitis (usually)

METABOLIC CAUSES OF ACUTE

ABDOMINAL PAIN
Diabetic Ketoacidosis
Acute intermittent Porphyria

ACUTE ABDOMEN BY AGE

12 -50 yrs

>50 yrs

NSAP

35%

15%

appendicitis

25%

10%

cholecystitis

6%

15%

SBO

3%

10%

Gynecologic disease

6%

1%

pancreatitis

3%

7%

diverticulitis

1%

5%

Vascular disease

1%

3%

hernias

1%

3%

COMMON SIGNS AND SYMPTOMS

Usually localized and severe pain or tenderness

Anxiety and fear
Voluntary and involuntary guarded positioning
Rapid and shallow breathing
Nausea, vomiting, or diarrhea
Shock
Absent bowel sounds (sometimes)
Constipation.
Depending on etiology, elevated temperature and rapid pulse, or
changes in blood pressure
Rigid or distended abdomen
GIT haemorrhage with haematemesis or passage of melaena stools
Flatulence

ABDOMINAL QUADRANTS
Used to describe areas of: Pain
Tenderness
Injury
Abnormalities

ABDOMINAL PAIN
Acute abdominal pain is the hallmark of an
acute abdomen
It may originate from any organ in the
abdominal cavity
Understanding the mechanisms of pain
production and the physiology of pain
perception allow for more accurate
diagnoses.

ABDOMINAL PAIN

Is a common cause of:visits to primary care providers

visits to emergency departments
hospital admissions in this country
missed work days.

TYPES OF ABDOMINAL PAIN

Two:-

Somatic and Visceral

SOMATIC
Nerve Impulse Carried by Somatic Nerves
T5 to L2 Level
Somatic Pain Caused by Irritation of the Parietal
Peritoneum
Sharp and Well-Localized
Often Associated With Muscle Spasm (Guarding)
Peritoneal Signs

VISCERAL
Nerve Impulse Carried by Sympathetic Branch
of the Autonomic Nervous System
Thoracic and Lumbar Level
Visceral Pain Caused by Irritation of the
Visceral Peritoneum
Pain Characterized as Dull and Poorly
Localized

VISCERAL
Pain Characterized as Dull and Poorly Localized
Foregut Epigastric Region
Midgut Periumbilical Region
Hindgut Hypogastric Region

EXAMPLE:
Classical Presentation of the Pain of Acute
Appendicitis
Starts in the Periumbilical Region (Visceral Pain
in the Midgut)
Then Migrates to the Right Lower Quadrant at
McBurneys point and is Associated with
Guarding (Somatic Pain and Secondary Muscle
Spasm)

REFERRED PAIN
Pain felt in an area of body distant from site of
pathology
The more severe the pain the more likely it is to
be referred
Due to existence of shared central neural
pathways for afferent nerves
Characteristic quality of many abdominal
processes
Kehrs sign

DIFFERENTIAL DIAGNOSIS OF AAP

Large List of Potential Diagnoses
Any List Will Inevitably Be Missing Diagnoses
Customary to Categorize By Quadrants

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Epigastrium
Peptic Ulcer Disease
Gastritis
ACS (Angina, MI)
Aortic Aneurism
Cholelithiasis
Diaphragmatic Defect Related
Paraesophageal Hernia, Gastric Volvulus, Congenital Diaphragmatic
Hernias
Gastroenteritis
Pancreatitis
Gastric Cancer, Pancreatic Cancer, etc.

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Right Upper Quadrant
Appendicitis (Retrocecal or Malrotated)
Cholelithiasis
Liver Related
Hepatitis, Abscess, Malignancy
Renal Related
Pyelonephritis,
Nephrolithiasis/Ureterolithiasis
Subdiaphragmatic Process
Abscess

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Left Upper Quadrant
Colonic Ischemia
Pancreatic - Pancreatitis, Tumor
Renal - Pyelonephritis,
Nephrolithiasis/Ureterolithiasis
Splenic - Infarct, Abscess
Subdiaphragmatic Process
Abscess.

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Mid-Abdomen/Periumbilical
Aortic Aneurism
Appendicitis
Small Bowel Obstruction
Ischemia (Intestinal Angina)
Gangrene

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Right Lower Quadrant
Appendicitis
Colon Related - Colitis (Especially Pseudomembranous),
Right- or Left-Sided, Diverticulitis, Cancer, Crohns Disease
Gynecological
Tubal Pregnancy, Ovarian Torsion, Cyst, PID, Tuboovarian
Abscess, Tumor, Endometriosis, etc.
Hernia
Inguinal, Femoral
Meckels Diverticulitis

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Right Lower Quadrant (Continued)
Renal
Pyelonephritis,
Nephrolithiasis/Ureterolithiasis
Typhlitis
Rectus/Retroperitoneal Hematoma

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Left Lower Quadrant
Colon Related - Colitis (Especially Pseudomembranous),
Diverticulitis, Cancer, Colonic Ischemia, Diverticulitis
Gynecological - Tubal Pregnancy, Ovarian Torsion, Cyst, PID,
Tubo-ovarian Abscess,Tumor, Endometriosis, etc.
Hernia - Inguinal, Femoral
Renal - Pyelonephritis, Nephrolithiasis/Ureterolithiasis
Torsion of Appendix Epiploica
Rectus/Retroperitoneal Hematoma

DIFFERENTIAL DIAGNOSIS BY
LOCATION
Suprapubic
Colon Cancer
Diverticulitis
Gynecological
Endometritis, Endometriosis, PID
Prostatitis
UTI

DIFFERENTIAL DIAGNOSIS BY
LOCATION
All Locations
Gastrointestinal Infections
Porphyria
Sickle Cell Crisis
Spontaneous Bacterial Peritonitis
Irritable Bowel Syndrome
etc.

PRINCIPLES OF MANAGING THE

ACUTE ABDOMEN
Early diagnosis is the key to improving
outcomes
An accurate history and complete physical
examination are more important than any
diagnostic test
The history should be obtained with the
abdomen bare, with attention to how the
patient positions himself/herself and moves.

PRINCIPLES OF MANAGING THE

ACUTE ABDOMEN
Identify the basic pathophysiologic process
responsible the patients clinical state.
Make a broad diagnosis
Determine whether an operation is necessary
Determine how urgent it is.
Resuscitate the patient
Assess the cardio-respiratory function
Obtain basic haematological and biochemical
measurements prior to surgery
X-ray, CT scan and FAST results.

INTESTINAL OBSTRUCTION
Interruption in the passage of intestinal
contents

CLASSIFICATION
1. Dynamic where peristalsis is working
against a mechanical obstruction.
2. Adynamic this may occur in two forms.
a. Peristalsis may be absent e.g. paralytic ileus.
b. Peristalsis present in a non-propulsive form e.g.
mesenteric vascular occlusion or pseudoobstruction.
In both types a mechanical element is absent.

ETIOLOGY OF DYNAMIC OBSTRUCTION

The obstructing lesion may be:
1. intraluminal, for example impacted
faeces, foreign bodies, worms Ascaris
lumbricoides, bezoar, gallstones;
2. intramural, for example malignant or
inflammatory strictures;
3. extramural, for example intraperitoneal
bands and adhesions, hernias, volvulus or
intussusception.

DYNAMIC OBSTRUCTION
Obstruction may be classified clinically into
two types:
Small bowel obstruction high or low;
Large bowel obstruction.

HIGH SMALL BOWEL OBSTRUCTION

Profuse vomiting occurs early

Rapid dehydration.
Distension is minimal
Little evidence of fluid levels on abdominal
radiography.

LOW SMALL BOWEL OBSTRUCTION

Pain is predominant
Central distension.
Vomiting is delayed.
Multiple central fluid levels are seen on
radiography.

LARGE-BOWEL OBSTRUCTION

Distension is early and pronounced.

Pain is mild
Vomiting and dehydration are late.
The proximal colon and caecum are
distended on an abdominal radiograph.

NATURE OF PRESENTATION OF I.O.

Influenced by whether the presentation is:
1. Acute;
2. Chronic;
3. Acute on chronic;
4. Subacute.
Presentation will be further influenced by whether
the obstruction is:
Simple where the blood supply is intact;
Strangulated there is direct interference to blood
flow, usually by hernial rings or intraperitoneal
adhesions/bands.

PATHOPHYSIOLOGY
Initially, proximal peristalsis is increased to
overcome the obstruction
If the obstruction is not relieved the bowel
begins to dilate causing a reduction in
peristaltic strength, ultimately resulting in
flaccidity and paralysis.
This is a protective phenomenon to prevent
vascular damage secondary to increased
intraluminal pressure.

CAUSE OF DISTENSION
Gas nitrogen (90 per cent) and hydrogen
sulphide.
Fluid this is made up of the various
digestive juices.
Following obstruction, fluid accumulates
within the bowel wall and any excess is
secreted into the lumen, whilst absorption
from the gut is retarded.

DEHYDRATION AND ELECTROLYTE

LOSS

are due to: reduced oral intake;

defective intestinal absorption;
losses due to vomiting;
sequestration in the bowel lumen.

STRANGULATION
Leads to a compromised blood supply to the bowel.
This may be due to:
1. External compression (hernial orifices/
adhesions/bands);
2. Interruption of mesenteric flow (volvulus, or
intussusception);
3. Rising intraluminal pressure (closed-loop
obstruction);
4. Primary obstruction of intestinal circulation
(mesenteric infarction).

CLOSED-LOOP OBSTRUCTION

Bowel obstruction is at both the proximal and distal point.

It is present in many cases of intestinal strangulation.
There is no early distension of the proximal intestine.
When gangrene of the strangulated segment is imminent,
retrograde thrombosis of the mesenteric veins results in
distension on both sides of the strangulated segment.
A classic form of closed-loop obstruction is seen in the
presence of a tight carcinomatous stricture of the colon with
a competent ileocaecal valve. The inability of the distended
colon to decompress itself into the small bowel results in an
increase in luminal pressure, greatest at the caecum, there is
impairment of blood supply, leading to necrosis and
perforation .

DIAGNOSIS OF INTESTINAL OBSTRUCTION

based on the classic quartet of:Pain,

Distension,
Vomiting,
Absolute constipation.

DIAGNOSIS OF INTESTINAL OBSTRUCTION

These features vary according to:

the location of the obstruction;
the age of the obstruction;
the underlying pathology;
the presence or absence of intestinal
ischaemia.

LATE MANIFESTATIONS

Include:Dehydration,
Oliguria,
Hypovolaemic shock,
Pyrexia,
Septicaemia,
Respiratory embarrassment
Peritonism.

Pain
Is the first symptom,
It occurs suddenly and is usually severe.
It is colicky in nature and is usually centred around
the umbilicus (small bowel) or lower abdomen
(large bowel).
Coincides with increased peristaltic activity.
With increasing distension, the colicky pain is
replace by a mild constant diffuse pain.
Severe pain is indicative of the presence of
strangulation.

VOMITING
The more distal the obstruction, the longer
the interval between the onset of symptoms
and the appearance of nausea and vomiting.
As obstruction progresses the character of
the vomitus alters from digested food to
faeculent material due to the presence of
enteric bacterial overgrowth.

DISTENSION
In the small bowel the degree of distension is
dependent on the site of the obstruction and
is greater the more distal the lesion. Visible
peristalsis may be present.
It is delayed in colonic obstruction and may
be minimal or absent in the presence of
mesenteric vascular occlusion.

CONSTIPATION
This may be classified as absolute (i.e. neither
faeces nor flatus is passed) or
relative (where flatus only is passed).
Absolute constipation is a cardinal feature of
complete intestinal obstruction.

EXCEPTIONS
The rule that constipation is present in
intestinal obstruction does not apply in: richters hernia;
gallstone obturation;
mesenteric vascular occlusion;
obstruction associated with a pelvic abscess;
partial obstruction (faecal impaction/colonic
neoplasm) where diarrhoea may often occur.

OTHER MANIFESTATIONS
DEHYDRATION
This is seen most commonly in small bowel
obstruction due to repeated vomiting and
fluid sequestration. This results in dry skin
and tongue, poor venous filling and sunken
eyes with oliguria.
The blood urea level and haematocrit rise
giving a secondary polycythaemia.

OTHER MANIFESTATIONS
HYPOKALAEMIA
An increase in serum potassium, amylase or
lactate dehydrogenase may be associated
with the presence of strangulation, as may
leucocytosis or leucopenia.

OTHER MANIFESTATIONS
Pyrexia in the presence of obstruction may
indicate: the onset of ischaemia;
intestinal perforation;
inflammation associated with the obstructing
disease.
Hypothermia indicates septicaemic shock.

ABDOMINAL TENDERNESS
Localized tenderness indicates pending or
established ischaemia.
The development of peritonism or peritonitis
indicates overt infarction and/or perforation.

CLINICAL FEATURES OF STRANGULATION

Strangulation is a surgical emergency.
In addition to the features outlined above,
the following should be noted:
Presence of shock
Sudden symptoms that recur regularly;
Localized tenderness associated with
rigidity/rebound tenderness.
In cases of io where pain persists despite
conservative management

RADIOLOGICAL DIAGNOSIS
Radiological diagnosis is based on a supine
abdominal film
When distended with gas the jejunum, ileum,
caecum and remaining colon have a characteristic
appearance that allows them to be distinguished
radiologically.
A barium follow-through is contraindicated in the
presence of acute obstruction and may be life
threatening.
Impacted foreign bodies may be seen on abdominal
radiographs.

MANAGEMENT OF ACUTE INTESTINAL

OBSTRUCTION

1.
2.
3.

There are three main measures:

Gastrointestinal drainage;
Fluid and electrolytic replacement;
Relief of obstruction, usually surgical.
The first two steps are always necessary prior to the surgical
relief of obstruction and are the mainstay of postoperative
management. In a proportion of cases, particularly adhesive
obstruction, they may be used exclusively.
Surgical treatment is necessary for most cases of intestinal
obstruction, but should be delayed until resuscitation is
complete, provided there is no:
Sign of strangulation;
Evidence of closed-loop obstruction.

ABDOMINAL INJURIES

GENESIS OF TISSUE INJURY IN

TRAUMA
A body remains in its state of rest or of
uniform motion unless compelled by an
external force to act otherwise. (Newton)
Force = mass x acceleration (Newton)
The Force that puts an object in motion must
be absorbed before the object stops.
This absorption is what causes tissue injury in
the body.

ANATOMICAL CONSIDERATIONS
ABDOMINAL CAVITY
Largest cavity in the body
Extends from the diaphragm to the pelvis
Contains several vital organ systems
1. Digestive
2. Genitourinary
3. Hepato-biliary
Vulnerable to trauma because of: Location
Lack of protective structures

ANATOMICAL CONSIDERATIONS
The abdominal cavity is divided into three
regions:
Peritoneal space
Retroperitoneal space
Pelvis

INTRAPERITONEAL STRUCTURES
a. Liver
b. Spleen
c. Stomach
d. Small bowel
e. Colon
f. Gallbladder
g. Female reproductive organs

RETROPERITONEAL STRUCTURES
a. Aorta
b. Vena cava
c. Pancreas
d. Kidneys
e. Ureters
f. Portions of the duodenum and large
intestines

PELVIC STRUCTURES
a. Rectum
b. Ureters
c. Pelvic vascular plexus
d. Major vascular structures
e. Pelvic skeletal structures
f. Reproductive organs

THREE TYPES OF ORGANS

Solid
Hollow
Vascular

ABDOMINAL TRAUMA
Eighty percent of all significant trauma
involves the abdomen.
Rapid, life-threatening bleeding can be hidden
in the abdomen
Retroperitoneum is difficult to evaluate
Initial abdominal exam often normal, and
many may be initially asymptomatic
Unrecognized abdominal injuries in the
multi-system trauma patient are the leading
cause of unexpected deaths.

CLASSIFICATION OF ABDOMINAL
INJURIES

Blunt injuries (closed)

Penetrating injuries

BLUNT TRAUMA
At least two thirds of all abdominal injuries
involve blunt trauma.
The damage is due to compression or
deceleration forces
In closed abdominal injury, soft-tissue
damage occurs inside the body, but the skin
remains intact.

BLUNT TRAUMA TO THE ABDOMEN

CAUSES
1. Motor vehicle crashes (RTA)
2. Falls
3. Assualt
4. Domestic violence
5. Bomb blasts
6. Falling debris from masonry
7. Sports, E.T.C.

MECHANISMS OF INJURY
Three common mechanisms of injury
a. Shearing: rapid deceleration forces, internal organs
continue forward motion, causing organs to tear at
their points of attachment to the abdominal wall
(liver, kidneys, small and large intestines, and spleen)
b. Crushing: abdominal contents are crushed between
the anterior abdominal wall and the spinal column
(kidneys, liver, and spleen)
c. Compression: direct blow or external compression
from a fixed object (deforms hollow organs)

BLUNT ABDOMINAL TRAUMA

Compressive or shearing
forces may deform and
rupture abdominal
organs
Bruising across the lower
abdomen is
characteristic of a seat
belt injury
Visible signs may not
reflect severity of
underlying injury

The Seat Belt Sign

SIGNS AND SYMPTOMS OF BLUNT

ABDOMINAL INJURIES
Abdominal pain
Distension
Discoloration of abdomen or flank
Unexplained shock

Blunt Abdominal Trauma

Flank ecchymosis from internal bleeding

BLUNT TRAUMA TO THE ABDOMEN

The spleen and liver are the organs most
commonly injured during blunt trauma.
Both can easily be crushed and both have a
large blood supply.
Few signs and symptoms may be present.

ASSESSMENT: PHYSICAL EXAM

Inspection, auscultation, percussion, palpation
Inspection: abrasions, contusions, lacerations,
deformity
Grey-Turner, Kehr, Balance, Cullen

Auscultation: careful exam advised by ATLS.

Percussion: subtle signs of peritonitis; tympany in
gastric dilatation or free air; dullness with
hemoperitoneum
Palpation: elicit superficial, deep, or rebound
tenderness; involuntary muscle guarding

PHYSICAL EXAM
Wound exploration in EXPERIENCED HANDS
Pelvis, perineum, rectal (part of a finger or
tube in every hole)

PHYSICAL EXAM:
Grey-Turner sign:
Bluish discoloration of lower flanks, lower back;
associated with retroperitoneal bleeding of pancreas,
kidney, or pelvic fracture.
Cullen sign:
Bluish discoloration around umbilicus, indicates
peritoneal bleeding, often pancreatic hemorrhage.
Kehr sign:
L shoulder pain while supine; caused by diaphragmatic
irritation (splenic injury, free air, intra-abd bleeding)
Balance sign:
Dull percussion in LUQ. Sign of splenic injury; blood
accumulating in subcapsular or extracapsular spleen.

MANAGEMENT

As always, ABCs
Primary survey
Secondary survey
Access
Fluid resuscitation
Search for blood loss and stop it

SOURCES OF BLEEDING IN ABDOMINAL

TRAUMA
Intraperitoneal causes
Liver
Spleen
Vessels

Extraperitoneal causes
Vessels
Kidneys

SECOND TIER ABDOMINAL

INJURIES
Bleeders take first priority, but:
May get bowel injuries with contamination
Pancreatic injuries with chemical injury
Mesenteric hematomas
Diaphragm injuries

INITIAL EVALUATION IN BLUNT

TRAUMA
ABCs
Access for fluids, blood products (IV line)
Blood for grouping and cross-matching most
important .
Rapid, focused history and physical
examination.
Prioritize life threats
Resuscitation comes before testing

EVALUATION OF BLUNT INJURIES

Plain films of the abdomen have virtually no
utility in the initial evaluation
1. Diagnostic Peritoneal Lavage
2. Ultrasound (F.A.S.T.)
3. CT scanning
4. Operating room
5. Others (urethrogram), angio-gram

AIS: ABBREVIATED INJURY SCORE

Score Abdominal injury example
1. Abdominal wall abrasion
2. Contusion to viscera
3. Minor liver, spleen laceration; bowel
laceration without perforation
4. Major liver, spleen laceration; bowel
perforation
5. Major visceral injury with tissue loss

FAST EXAMINATION
Focused Assessment by Sonography for
Trauma
Screens for free fluid, presumed to be blood in
the trauma setting
Decision scheme for positive FAST exam is
based on clinical scenario

FAST IMAGES
4 views to be obtained
RUQ view (fluid in Morrisons pouch)
LUQ view (fluid in splenorenal space)
Subxyphoid (pericardial fluid)
Suprapubic (fluid around bladder)
Some get additional views to look for pneumo or
haemothorax!

TREATMENT DECISIONS WITH

FAST
Positive FAST + unstable
patient

Positive FAST + stable

patient

Operating room

CT evaluation

Negative FAST + unstable

patient
Continue resus, consider other
causes, repeat FAST, DPL, or
OR if continues unstable after
adequate resuscitation

Negative FAST + stable

patient
CT evaluation or observation

DOES FAST REPLACE CT?

Only at the extremes.
Unstable patient, (+) FAST OR
Stable patient, low force injury, (-) FAST
consider observing patient.
CT is far more sensitive than FAST for detecting and
characterizing abdominal injury in trauma. The
gold standard for characterizing intraparenchymal
injury.
Death begins with a CT. Never send an unstable
patient to CT. FAST, however, can be performed
during resuscitation.

DPL
Catheter inserted into abdomen, aspirate
If no gross blood, bile or stool, then lavage
with liter of saline
Contraindications exist
In general, positive if:
> 100,000 RBC/mm3
>500 WBC/mm3
Gram stain + for bacteria

Routines for Surgical Emergency

Abdominal puncture and peritoneal lavage

Abdominal puncture and peritoneal lavage

Contraindications

Previous abdominal procedures

Presence of dilated bowel
Late pregnancy
Positive needle para-centesis.

CT SCANNING
As opposed to FAST exams, CT is a very
specific diagnostic study
Will visualize retroperitoneum as well as
intraperitoneum
Must have stable patient to get CT scan
Takes time.

Comparison of Diagnostic Studies

FAST

CT

DPL

Cost

cheap

expensive

cheap

Invasive

no

no

yes

Sensitive

yes

yes

yes

Specific

no

yes

no

Repeatable

yes

yes

no

Rapid

yes

no

yes

LAPARATOMY
Indications to go under the knife
Blunt trauma with positive DPL or unstable patient
with positive F.A.S.T.
Blunt trauma with recurrent hypotension despite
resuscitation
Peritoneal signs
Penetrating wound with hypotension
GSW across peritoneal cavity, visceral
retroperitoneum

LAPARATOMY
Indications to go under the knife
GI or GU bleeding from penetrating trauma
Evisceration
Free air, retroperitoneal air
Ruptured diaphragm
CT evidence of ruptured GI tract, renal pedicle
injury, intraperitoneal bladder rupture, or severe
perenchymal injury

COMMON INJURY PATTERNS

In patients undergoing
laparotomy for blunt trauma,
most frequently injured
organs are spleen (40-55%),
liver (35-45%), and small
bowel (5-10%). (ATLS, 2001)

SPECIFIC INJURIES
Diaphragm
left hemidiaphragm more commonly injured
elevation on CXR, but may be normal
difficult to visualize injuries by other means
(including CT, MRI)
injuries may be missed for years

SPECIFIC INJURIES
Duodenum

often in unrestrained drivers,

handlebar injuries
suspect with history, blood in NGT
aspirate, or retroperitoneal air

SPECIFIC INJURIES
Pancreas

often from direct blow compressing

pancreas against vertebral column
very difficult to evaluate, even with CT

SPECIFIC INJURIES
Small bowel
can be from penetration or tearing from
compression or deceleration
think of injury with seatbelt sign
DPL good at detection transluminal
injuries, but small bowel bleed little, may
be negative
F.A.S.T. and CT not good for small bowel

SPECIFIC INJURIES
Solid organs commonly injured
spleen #1 in blunt
liver #2 in blunt, #1 in stabs
Management depends on
extent/grading of injury
observation for small subcapsular
tears
emergent laparotomy for grade IV

SPECIFIC INJURIES
Kidneys
can be from both blunt and penetrating
management also depends on
severity/grading

SPECIFIC INJURIES
Pelvic fractures
numerous blood vessels, may result in
massive hemorrhage
usually massive forces involved
classifications based on forces causing
injuries
if unstable fracture, must be reduced to
control hemorrhage

SPECIFIC INJURIES
Vascular injuries

aorta, IVC
can result in massive hemorrhage
much more likely form penetrating
injury

PENETRATING TRAUMA
Gun shots, Knives, and Sharpnel
Injury is produced when missile
dissipates energy to tissue as it passes
through
Wound created depends on nature of
missile, involved tissue and speed of
projectiles
V2.5 9/03

PENETRATING ABDOMINAL
TRAUMA
Visible wounds may
not reflect severity of
underlying injury
Significant internal
bleeding likely
Bowel injury likely
Patient may be in
shock

EVALUATION AND EXAMINATION

Visually note wounds and
abrasions
Palpate abdomen for
localized vs. diffuse
tenderness
Consider possible internal
injuries
Diffuse, severe tenderness
is a sign of internal
bleeding

DONT FORGET THE BACK

Turn the casualty
over when you can
do so safely
Visually inspect back
Palpate ribs, spine,
sacrum for
tenderness and
irregularities
Dress the wound
with an occlusive
dressing

IMPALEMENT INJURY

IMPALEMENT INJURIES
DO NOT REMOVE OBJECT OR
EXERT ANY FORCE UPON IT!

Severe bleeding may

occur causing shock
Check pulses distal to
impaled object
Immobilize the object
Apply bulky support
bandages to hold in
place

BLAST INJURIES
Primary Blast Injury
Pressure wave injury to air-filled organs
GI,
barotrauma
Secondary Blast Injury
Result from sharpnel/debris
Penetrating and Blunt trauma
Majority of casualties
Tertiary Blast Injury
Patient becomes a missile resulting in injuries
V2.5 9/03

PRIMARY BLAST INJURY

Injuries to Air-Filled Organs

Due to Explosion
LUNGS
GI TRACT
EARS
V2.5 9/03

PBI: GI System
Gas-containing abdominal structures injured in
similar manner and overpressure as lung
Colon > small bowel (more air)
Rupture - acute or delayed after stretching,
ischemia, bowel wall weakening
Shear forces may tear mesentary
Non-bowel injuries more likely from conventional
blunt / penetrating mechanisms
V2.5 9/03

PBI: GI System
Signs & Symptoms
Abdominal Pain
Nausea /Vomiting
Diarrhea
Decreased Bowel
Sounds
Rebound / Guarding

V2.5 9/03

MANAGEMENT OF BLUNT AND PENETRATING

ABDOMINAL TRAUMA EMERGING TRENDS

Permissive hypotension - Also called

hypotensive resuscitation
An increasingly accepted view holds that
moderate hypotension systolic blood
pressure of 8590 mmHg is sufficient to
maintain vital organ perfusion and avoids a
hypertensive overshoot with the risk of
precipitating further haemorrhage.

REFERENCES

Hoff et al. EAST Practice Management Guidelines Work

Group. Practice Management Guidelines for the Evaluation
of Blunt Abdominal Trauma, 2001. www.east.org.
American College of Surgeons Committee on Trauma.
Advanced Trauma Life Support for Doctors; Student Course
Manual, 7th edition, 2004.
Scalea TM, Rodriquez A, Chiu WC. Focused Assessment
with Sonography for Trauma (FAST): Results from an
International Consensus Conference. J. Trauma
1999;46:466-472.
Yoshii H, Sato M, Yamamoto S. Usefulness and Limitations
of Ultrasonography in the Initial Evaluation of Blunt
Abdominal Trauma. J. Trauma 1998;45:45-51.
Tina Gaarder, MD, PhD .Clinical management of abdominal
trauma

THANK YOU