Injury of the abdomen - Causes, symptoms and treatment. MF.

Given the rhythm of the life of the modern city, as well as the dangers that lurk in it, it is not surprising that abdominal trauma remains one of the urgent problems of emergency surgery. Allocate an open and closed abdominal trauma.

Open injuries include injuries( knife, gunshot, including traumatic weapons).With the injuries of the abdomen, the algorithm of actions is simple enough - to immediately seek medical help in the on-duty surgical hospital, since even without damaging the internal organs, it is necessary to perform a primary surgical treatment of the wound and to place sutures. Stitches can be applied no later than 8 hours after the injury, because after a longer period of time the risk of suppuration of the wound is high.

Closed or blunt trauma is an abdominal wall injury with or without damage to the internal organs. Let us consider them in more detail. To blunt trauma of the abdomen include: a bruise of the abdominal wall, rupture of the muscles of the abdominal wall, damage to the intestines, liver, spleen, pancreas, kidneys, bladder.

Causes of blunt abdominal trauma

The causes of blunt abdominal trauma can be:

• falling on a solid object,
• bumps,
• abrupt abdominal wall muscle strains during physical exercises or sneezing, coughing.

Symptoms of blunt abdominal trauma

Contusion of the abdominal wall is manifested by local swelling and tenderness, sometimes visible abrasions, hemorrhages. Soreness increases with a change in body position, coughing, sneezing, act of defecation.

The rupture of the muscles and fascia of the abdominal wall is characterized by the same signs, but the pain is more pronounced, resulting in reflex paresis of the intestine( dynamic intestinal obstruction) and bloating.

When a muscle rupture, hemorrhages develop and hematomas can form, which sometimes spread far beyond the site of the injury. The final diagnosis of damage to the anterior abdominal wall is made when the rupture of the hollow or parenchymal organs of the abdominal cavity is excluded.

With a direct stroke in the abdomen, ruptures of the small intestine are most common.

The main symptoms of bowel rupture are: the spreading and increasing pain in the abdomen, the tension of the muscles of the abdominal wall, the restriction of the respiratory movements of the abdominal wall, vomiting, increased heart rate, and shock phenomena.

With , the large intestine rupture in addition to these symptoms often causes shock, intraperitoneal bleeding, abdominal wall tension.

Damage to the liver with abdominal trauma occurs frequently. This is due to the large size of the liver and its location, as well as the low elasticity and fragility of its parenchyma. With pathological changes in the parenchyma, liver ruptures can also occur with a minor trauma( falling on level ground, childbirth, act of defecation).Gaps and cracks can be subcapsular, but with a significant injury, separate parts of the liver come off. Clinically, liver damage is accompanied by a severe general condition, blood loss and loss of consciousness, which occur soon after getting injured. The arterial pressure drops, the pulse becomes faster, the skin becomes pale, sweaty, breathing becomes more frequent, thirst arises. Especially dangerous are podkapsulnye liver ruptures, when a calm clinical flow forms a deep hematoma under the capsule of the liver, with the tension of which the capsule of the liver is ruptured, and the blood is poured into the abdominal cavity. With the saved consciousness there are pains in the right hypochondrium with spreading to the right shoulder.

Damage to the spleen among all injuries of the abdominal cavity is about 30%.Subcutaneous primary splenic rupture can occur even with mild trauma or for no apparent reason, if the spleen is enlarged and has parenchymal changes. Secondary, or late, splenic ruptures are possible in a few days or months after the injury and are observed more often in children.

Immediately after the rupture of the spleen capsule, the bleeding stops with a formed blood clot. If the splenic parenchyma rupture occurs subcapsularly, the growing hematoma ruptures the capsule and massive bleeding occurs in the abdominal cavity. The rupture of the spleen, accompanied by bleeding, is characterized by a marked drop in blood pressure and a frequent thread-like pulse. Pain decreases in the supine position on the left side with the legs brought to the abdomen. The pains are localized in the left hypochondrium, sometimes spread all over the stomach and into the left shoulder.

In such cases, when there are signs of rupture of the spleen, urgent surgery is indicated.

Damage to the pancreas , located behind the abdominal organs, occurs when the abdomen is of considerable strength and is therefore often accompanied by traumatism of the surrounding organs( spleen, kidney, liver, intestine).

Closed abdominal injuries can cause concussion, bruising, or rupture of the pancreas.
The clinical picture of any damage to the pancreas is characterized by a general severe condition, sharp pains in the epigastric region( under the spoon), a drop in arterial pressure, vomiting, bloating and protective muscle tension in the epigastric region.

Damage to the kidney of the , located deep in the retroperitoneal space and surrounded by organs and massive anatomical formations on all sides, occurs infrequently. The kidneys are injured most often with a direct local shock from behind, from the side or from the front. The clinical picture is characterized by local soreness in the lumbar region, an increase in temperature, macrogematuria( urine colored with blood in pink-red color).

In both cases, conservative treatment is performed.

There are crushing and detachment of the kidneys that occur during gross trauma and are often combined with damage to the abdominal organs. A typical picture: shock state, increasing anemia, local soreness and muscle tension in the corresponding hypochondrium, swelling in the lumbar region, with rupture of the peritoneum - free fluid in the abdominal cavity;hematuria may be absent.

When falling on a solid object, striking the stomach with a filled bladder can break it.

With extraperitoneal , the bladder rupture of causes false urination to urinate, in some cases a small amount of bloody urine is released. Soon there is swelling in the perineum.

With intraperitoneal rupture of the bladder, there are abdominal pains and frequent infertile urination to urinate, since the bladder is empty. Urine poured into the abdominal cavity irritates the peritoneum and causes peritonitis( soft, slightly swollen, moderately painful abdomen, weakened intestinal peristalsis).A free liquid is defined in the loin areas of the abdomen.

Examination for abdominal trauma.

If you suspect a stomach injury, you should go to the on-duty surgical hospital.

Timely diagnosis of damage to internal organs is the key to successful treatment. It is extremely important to establish the nature of the damage in the shortest possible time, first of all to establish the presence of a life-threatening bleeding.

If you suspect a stomach injury, you need to give a general blood test, a general urine test and urine amylase, determine the blood group and the Rh factor. These methods are of an auxiliary nature, for the specification of the damaged organ ray methods of research are used, which include ultrasound examination, traditional X-ray study and, if possible, perform computed tomography. The need for using this or that method is determined by the surgeon, focusing on the severity of the patient's condition and the data obtained during the examination of the patient.

The ultrasound is the safest, most affordable and fastest method of diagnosis in case of suspected abdominal trauma. It allows to identify patients who need to perform urgent surgery: to establish the presence of intra-abdominal bleeding, as well as to detect damage to organs that have not yet led to intra-abdominal hemorrhage: subcapsular rupture of the spleen, hematoma of the liver and spleen, damage to the kidneys and pancreas.

Ultrasonic picture of subcapsular hematoma of the spleen.

X-ray examination of allows to reveal the rupture of the hollow organ with blunt abdominal trauma, to detect foreign bodies and to determine their location( for example, bullets and shot with gunshot wounds to the abdomen), to detect pelvic damage, to assess the concomitant damage to the chest organs, to reveal the rupture of the diaphragm.

Free gas in the abdominal cavity.

To clarify the diagnosis, the bladder rupture is successfully applied by the catheterization of the bladder. When it is ruptured, a small amount of blood is released through the catheter. In doubtful cases, ascending cystography is performed: a water-soluble contrast solution is injected into the bladder through the catheter. The radiocontrast solution penetrates through the wound of the bladder into the perivascular tissue, and on the roentgenogram it is visible.

Computed tomography is a more accurate method of diagnosis, it allows more accurate assessment of the structure of internal organs, to establish a small amount of blood in the abdominal cavity. However, this method requires more time, is not always available due to expensive equipment.

Laparoscopy - a method of visual assessment of internal injuries, consists in insertion of the endoscope into the abdominal cavity through a small incision( 1 - 2 cm) under local anesthesia. Laparoscopy allows you to finally determine the presence of internal injuries, often stop bleeding, sanitize the abdominal cavity from the bleeding and set the indications for an emergency operation.

Treatment of stomach injuries.

After getting injured, it is necessary to refrain from eating food and liquids, because if an internal injury is found, anesthesia operation is required, in which vomiting with aspiration of food into the respiratory tract is possible.

In the presence of cut wounds of the abdominal wall that do not penetrate into the abdominal cavity, primary surgical treatment is performed under local anesthesia and stitches are applied, as mentioned earlier.

When confirming the diagnosis of intra-abdominal bleeding, rupture of the hollow or parenchymal organ, it is necessary to perform a wide median laparotomy( median incision along the anterior abdominal wall).Allowing to examine all the organs of the abdominal cavity, establish the damaged organ and perform the necessary volume of the operation.

The subcapsular rupture of the spleen requires dynamic observation. It is dangerous for a possible delayed rupture of the capsule with heavy bleeding into the abdominal cavity - the so-called two-moment rupture of the spleen, which will require an emergency operation.

Injuries to the anterior abdominal wall with muscle rupture and hematoma development require conservative treatment, including bed rest, local cold application and physiotherapeutic procedures that promote hematoma resorption. With a large size of the hematoma, puncture can be performed, and with suppuration, opening and draining of the abscess formed.

Complications of abdominal injuries:

• A rupture of the muscles of the abdominal wall after a certain time can lead to the appearance of a hernia.
• Intra-abdominal bleeding without appropriate timely treatment is life threatening.
• The rupture of the hollow organ without a timely operation causes the development of peritonitis( inflammation of the peritoneum), which leads to sepsis( blood infection) and death.

Positive outcome in case of stomach injury is possible only with the early application of medical care. Take care of your health. It is better to overestimate the severity of your symptoms than it is too late to seek medical help.

Surgeon-physician Tevs DS