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CHAPTER 29

Abdominal Trauma

Emmanuel A. Ameh Iyore A. Otabor
Lohfa B. Chirdan Benedict C. Nwomeh

Introduction with head injury or depressed sensorium, so repeated examination or
Abdominal trauma is common in children, accounting for about 5% other diagnostic tests are often necessary in such patients.
of admissions to major paediatric centres. Most injuries are blunt in Decompression of the stomach with a nasogastric tube and the
1–5
nature, but the incidence of penetrating trauma injuries is increasing. passage of a urethral catheter (except if there is blood at the external
Although most blunt trauma injuries result from traffic injuries, falls meatus or a floating prostrate) may be helpful when examining children
(frequently off fruit-bearing trees) are particularly important in sub- with blunt abdominal trauma. Rectal examination should be done to
Saharan Africa and other developing countries. 1,3,6 Firearms, bicycles, look for perianal soilage with blood, tenderness, floating prostate, or a
sports, and injuries inflicted as a result of child abuse are becoming palpable rent in the rectum. The examining finger should be inspected
increasingly noticeable in developing countries. 7–8 for blood stain.
A number of factors make children particularly vulnerable to The chest, central nervous system and musculoskeletal system
abdominal injury. The relatively thin abdominal wall and lower rib should be examined to exclude injury in these systems.
cage in children means that the liver, kidney, and pancreas lie in close Investigations
proximity to the anterior abdominal wall and are prone to injury even if Relevant investigations of a child with abdominal trauma would
the cause of trauma is trivial. Besides, the liver and kidneys, which are include the techniques discussed in the following subsections.
normally protected by the rib cage in adults, lie relatively lower in the
abdomen of the child, making them vulnerable to injury. The liver also Abdominal Ultrasonography
occupies a proportionately larger percentage of the child’s abdomen, Focused abdominal sonography for trauma (FAST) is directed at identi-
further exposing it to increased risk of injury. fying intraperitoneal or pericardial fluid, which may result due to solid
Abdominal trauma is frequently associated with other extraabdominal organ injuries (spleen, liver, kidneys, heart). When available, it could be
injuries, which should not be overlooked. A distended stomach and full used as a screening tool in the immediate assessment of blunt abdomi-
bladder may interfere with the evaluation of the injured child, and may nal trauma. The FAST examination evaluates four areas:
need to be promptly emptied. The initial assessment and resuscitation 1. right upper quadrant including the hepatorenal fossa;
of the injured child is detailed in Chapter 27.
2. left upper quadrant including the perisplenic region;
Blunt Abdominal Trauma 3. right and left paracolic gutters and the pelvis; and
3
Blunt injury accounts for up to 86% of abdominal trauma. In children, 4. intercostal or subdiaphragmatic view of the heart.
blunt abdominal trauma produces a spectrum of injuries that may pose Note that the FAST examination does not always identify injured
diagnostic and treatment challenges in the African setting, with its solid organs, and its sensitivity depends on the skills of the operator.
4
limited diagnostic facilities. Special attention should be directed at Diagnostic Peritoneal Lavage
handlebar injuries (which cause focused liver, pancreatic, duodenal,
The aim of diagnostic peritoneal lavage (DPL) is to detect bleeding or
and jejunal injuries); lap-belt injuries (which produce a triad of abdomi-
leakage of intestinal contents or pancreatic juice into the free peritoneal
nal abrasion, intestinal perforation, and intestinal laceration), and child
cavity. This investigation is used for the evaluation of a traumatised
abuse (in which the face and head may be involved). Bowel injuries
6
may also cause significant morbidity due to a delay in diagnosis. child who is unstable. It may require urgent laparotomy for deteriorat-
ing neurologic status or when the source of blood loss or clinical find-
Clinical Evaluation ings are in doubt. DPL may be very helpful in resource-poor settings,
After the initial evaluation, resuscitation, and stabilisation, the child where advanced imaging modalities are not available, to select patients
with blunt abdominal trauma is carefully and thoroughly evaluated. who need operative intervention.
An additional history is obtained, paying particular attention to vomit- DPL is performed by placing a catheter under direct vision into the
ing, haematemesis, or rectal bleeding, which may indicate rectal or peritoneal cavity. In infants with no previous surgery, a plastic-sheathed
proximal intestinal injury. A history of loss of consciousness should be needle is passed obliquely into the lower quadrant. In older children
sought, as this may indicate head injury. without previous surgery, the catheter may be passed by using the
The presence of pallor, abdominal distention, and pain on physical Seldinger technique. A positive result is obtained when blood, intestinal
examination may be a pointer to intraabdominal bleeding. The pulse contents (bile-stained fluid), or free peritoneal air is encountered. If
rate should be carefully monitored, as it is a more sensitive indicator free fluid is obtained, 15 ml/kg body weight of Ringer’s lactate or
than blood pressure of haemodynamic status in children. Careful normal saline is introduced into the abdominal cavity and the effluent
examination of the abdomen is performed, with particular attention to is analysed for red blood cells (RBC) (> 50,000/ml), white blood cells
abrasions, bruises, distention, and tenderness. Note that peritoneal signs (WBC) (>500/ml), and the presence of intestinal contents and amylase.
are particularly difficult to discern in a child with lower rib fractures, In children, the presence of blood alone at DPL is not necessarily an
contusion or abrasions of the abdominal wall, pelvic fractures, and indication for operation because it could be due to solid organ injuries
distended bladder. Abdominal examination may be unreliable in patients that can be managed nonoperatively.