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]Enderson BL, Reath DB, Meadors J, et al. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990 Jun;30(6):666-9.
http://www.ncbi.nlm.nih.gov/pubmed/2352294?tool=bestpractice.com
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]National Highway Traffic Safety Administration. Fatality analysis reporting system (FARS): 2016. September 2017 [internet publication].
http://www-fars.nhtsa.dot.gov/Main/index.aspx
In about one third of these deaths, alcohol was involved.[3]National Highway Traffic Safety Administration. Traffic safety facts: 2016 data. October 2017 [internet publication].
https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812450
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]American College of Emergency Physicians. Motor vehicle safety. Ann Emerg Med. 2009 May;53(5):698.
http://www.ncbi.nlm.nih.gov/pubmed/19380055?tool=bestpractice.com
[5]Centers for Disease Control and Prevention (CDC). Impact of primary laws on adult use of safety belts - United States, 2002. MMWR Morb Mortal Wkly Rep. 2004 Apr 2;53(12):257-60.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5312a2.htm
http://www.ncbi.nlm.nih.gov/pubmed/15057190?tool=bestpractice.com
[6]Allen S, Zhu S, Sauter C, et al. A comprehensive statewide analysis of seatbelt non-use with injury and hospital admissions: new data, old problem. Acad Emerg Med. 2006 Apr;13(4):427-34.
https://onlinelibrary.wiley.com/doi/epdf/10.1197/j.aem.2005.11.003
http://www.ncbi.nlm.nih.gov/pubmed/16531597?tool=bestpractice.com
[7]Goss CW, Van Bramer LD, Gliner JA, et al. Increased police patrols for preventing alcohol-impaired driving. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005242.
http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005242.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/18843684?tool=bestpractice.com
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]Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:56.
https://www.doi.org/10.1186/s13017-019-0278-6
http://www.ncbi.nlm.nih.gov/pubmed/31867050?tool=bestpractice.com
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]Centers for Disease Control and Prevention. Fatal injury reports, national, regional and state, 1981 - 2020. Feb 2020 [internet publication].
https://wisqars.cdc.gov/fatal-reports
Of these deaths, 38,850 were intentional (i.e., suicide or homicide) and 486 were accidental.[9]Centers for Disease Control and Prevention. Fatal injury reports, national, regional and state, 1981 - 2020. Feb 2020 [internet publication].
https://wisqars.cdc.gov/fatal-reports
In European countries, firearm-related injuries are much less common.[10]Krüsselmann K, Aarten P, Liem M. Firearms and violence in Europe-a systematic review. PLoS One. 2021;16(4):e0248955.
https://www.doi.org/10.1371/journal.pone.0248955
http://www.ncbi.nlm.nih.gov/pubmed/33852590?tool=bestpractice.com
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]Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma. 2003 Dec;55(6):1095-108.
http://www.ncbi.nlm.nih.gov/pubmed/14676657?tool=bestpractice.com
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]Powell BS, Magnotti LJ, Schroeppel TJ, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May;39(5):530-4.
http://www.ncbi.nlm.nih.gov/pubmed/18336818?tool=bestpractice.com
