66.1 The general method for an abdominal injury

The organs in a patient’s abdomen can be injured by a stab from a sharp object, or a blow from a blunt one. As Hippocrates knew, the gut can be ruptured, even if there is no visible mark on the abdominal wall. A patient can die from bleeding into his peritoneal cavity, especially from rupture of his spleen or liver, or from a leaking gut. Your main tasks are: (1) to diagnose that a patient has an abdominal injury, (2) to stop it bleeding, (3) to suture his injured small gut. Occasionally, (4) you will need to exteriorize his injured large gut. He has at least a 50% chance of having at least one other severe injury, so you will have to treat that too.

Figure 66.1: AN ABDOMINAL INJURY can injure a patient’s spleen, his liver, his gut, his kidneys, or his bladder. Kindly contributed by Peter Bewes.

Blunt injuries are particularly difficult because: (1) A patient may give no clear history that he has had an abdominal injury, especially if he is a frightened child. His injury may be so mild that you have to question him carefully, and he may even walk into hospital. (2) His other more obvious injuries, such as a fractured femur, may distract your attention. (3) He may be drunk, or unconscious from a head injury and unable to tell you his symptoms. If you anaesthetize him to treat his other injuries, he cannot complain of increasing abdominal pain. (4) For the first few hours after a blunt injury his abdomen may be deceptively normal. Although a haemoperitoneum usually causes pain, tenderness, guarding, and absent bowel sounds, it occasionally causes none of these things, especially in children. (5) Distinguishing between muscle pain and peritoneal irritation can be very difficult. (6) Some injuries may not show themselves for several days, especially a subcapsular haematoma of the spleen, or a retroperitoneal injury of the pancreas or duodenum.

For all these reasons, abdominal injuries need particular judgement, care, and skill. So, be vigilant and suspicious. You will need a watchful eye, a light touch, and a sympathetic ear. Don’t let a patient go ome if there is even a slight possibility that he might have injured his abdomen. If you are in any doubt, observe him carefully and use the special methods described below. They will be particularly useful if he also has a head injury, and may indeed save his life. The decision to operate will be much more difficult if you have already anaesthetized him to reduce a fracture, and he is already on traction or in a cast. If he is going to need a laparotomy, try to do it early.

MURAV ULAL was a sailor who fell on to a crate. In the casualty department no injuries were found and his blood pressure was normal. However, the casualty officer was worried about the possibility of an abdominal injury, because there was an abrasion on his epigastrium, so she admitted him. When the registrar saw him in the ward half an hour later he was severely shocked. Urgent laparotomy revealed a ruptured spleen.

MOHAN (25) had been kicked in the abdomen during a fight. His abdomen was bruised and abraded, but he did not look as if he had been seriously injured. The medical assistant who saw him gave him aspirin and sent him home. Three days later he was admitted with severe peritonitis. A quantity of pus and intestinal contents were removed from his abdomen, but he died soon afterwards. LESSONS (1) Any abdominal abrasion after a blunt injury should make you suspect an internal injury. (2) A young adult can maintain his blood pressure for some hours after an injury, and it may even rise before it falls catastrophically.