Evaluation of abdominal trauma in adults

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 collisions (MVCs), motorcycle crashes, pedestrian-automobile impacts, falls, and assaults. MVCs are the most common cause of blunt abdominal trauma. In the US in 2022, there were 42,514 motor vehicle traffic fatalities.[2]National Highway Traffic Safety Administration. Traffic safety facts: overview of motor vehicle traffic crashes in 2022. Jun 2024 [internet publication]. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813560 ​ Alcohol-impaired-driving accounted for 32% of overall traffic fatalities.[2]National Highway Traffic Safety Administration. Traffic safety facts: overview of motor vehicle traffic crashes in 2022. Jun 2024 [internet publication]. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813560 ​​ 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.[3]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 [4]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 [5]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 [6]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 such as small hemodynamically insignificant liver, spleen, or kidney lacerations, to devastating injuries requiring immediate intervention. Bowel injuries generally require surgical repair to prevent peritonitis and septic shock.[7]Smyth L, Bendinelli C, Lee N, et al. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg. 2022 Mar 4;17(1):13. https://wjes.biomedcentral.com/articles/10.1186/s13017-022-00418-y http://www.ncbi.nlm.nih.gov/pubmed/35246190?tool=bestpractice.com

Diaphragmatic injury is uncommon in trauma patients, comprising 0.46% (3873) of all encounters in the National Trauma Data Bank in 2012 (833,309).[8]Fair KA, Gordon NT, Barbosa RR, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015 May;209(5):864-8. http://www.ncbi.nlm.nih.gov/pubmed/25952278?tool=bestpractice.com ​Injuries to the spleen were more commonly reported among patients with blunt traumatic diaphragmatic injury than those with penetrating injury (44.8% vs. 29.1%).[8]Fair KA, Gordon NT, Barbosa RR, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015 May;209(5):864-8. http://www.ncbi.nlm.nih.gov/pubmed/25952278?tool=bestpractice.com

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 and in the military.[9]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 more than 40,000 firearm-related deaths occurring in 2022.[10]Centers for Disease Control and Prevention. CDC WISQARS national violent death reporting system. 2021 [internet publication]. https://wisqars.cdc.gov/fatal-reports In European countries, firearm-related injuries are much less common.[11]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.[12]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.[13]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 An analysis of National Trauma Data Bank found that, of 3873 traumatic diaphragmatic injury encounters in 2012, penetrating injuries were more common than those attributable to a blunt mechanism (67% [2543] vs. 33% [1240], respectively).[8]Fair KA, Gordon NT, Barbosa RR, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015 May;209(5):864-8. http://www.ncbi.nlm.nih.gov/pubmed/25952278?tool=bestpractice.com ​​