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KMID : 0381219720040070424
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Journal of RIMSK
1972 Volume.4 No. 7 p.424 ~ p.429
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DIAGNOSIS AND TREATMENT OF ABDOMINAL TRAUMA
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Abstract
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Abdominal trauma can be grouped into a blunt and a penetrating type. The latter can be further divided into stab and penetrating wound. The high incidence of multiple abdominal visceral injuries and the greatest incidence of associated injuries cause high incidence of mortality among the patients with blunt abdominal trauma. Most frequently encountered associated extra-abdominal injuries are rib fractures, long bone fractures, craniocerebral injuries, pulmonary and pelvic bone involvements.
Over-all mortality of blunt abdominal injury ranges between 10~20% according to literature. This mortality increases up to 4 or 5 times, if associated extra-abdominal injuries are present.
As a rule, an indication for surgical intervention is more clear cut in case of penetrating wound than blunt trauma. The organs most frequently injured by trauma in the upper abdomen are spleen, liver and small bowel, duodenum and pancreas in the order of frequency. More than half of the patients in abdominal trauma had sustained injury to more than one organ in the literature. Prior to the establishment of definite diagnosis, it should be stressed that all case a of abdominal trauma should have prompt resuscitation first, if it is required.
Without establishment of an adequate airway and maintenance of an adequate circulation, nothing can be proceeded further. In the presence of associated extra-abdominal injuries, surgeon has to decide the order of treatment for the relief of immediate life threatening injury first.
Diagnostic procedure should be minimal for the severely injured patient. Most of time it is possible to diagnose the patient by simple physical examination in abdominal trauma. Patients who have good vital signs and are in good general condition, but are dubious cases in diagnosis should have more thorough diagnostic work-up, even with sophisticated diagnostic measurements.
Diagnostic paracentesis is the most simple and effective way to diagnose intraabdominal pathology. Bilateral flank or 4-quadrant tap doesn´t make much difference in its effect.
Hypaque sinogram is useful for the diagnosis of intra-peritoneal pathology, but its negative findings can´t exclude the possibility of abdominal exploration. All patients who have penetrating abdominal wound are potential candidates for surgery, regardless whether they present peritoneal signs or not.
At least, following picture should be taken.
a. Upright cheat P-A
b. Abdominal supine A-P
c. Prone abdomen P-A
d. Left lateral decubitus abdomen
e. Upright abdomen
In addition to these, selective arteriography, isotopic scanning, I. V.?. cystogram, and upper G-I series using water soluble contrast media can be utilized.
The following statement can be made in general for the abdominal trauma patients, the shorter the time between injury and operation, the better the result. Injury to specific intraabdonimal organs are mentioned, particular reference to organ specific characteristics of management.
Stomach is injured mostly due to stab and penetrating wound. The wound can be repaired by debridement, simple closure, and occasionally gastrectomy is required.
Duodenal wounds are managed by the much same principle with the stomach. Retroperitoneal wound of duodenum are relatively difficult to diagnose early. So that repeated examination is necessary. Large defect in the duodenal wall can be patched with jejunal wall. Intramural herratoma of duodenum should be removed as early as possible for the prevention of duodenal rupture and relief of obstruction. Pancreatic injuries are managed in three ways. These are simple drainage, simple closure and drainage,
resection and some kind of by-pass procedure. Excellent reports are published in the radical resection for the pancreatic injury, such as Whipple´s operation. Most frequent complication after surgery are bleeding, fistula and abscess formation.
Some advocate an increasing use of resection in the management of complicated wounds of pancreas.
The management of hepatic injury includes precise control of hemorrhage, debridement of devitalized tissue with extensive drainage and debridement resection. Irrespective of the type of treatment, drainage should be placed always, for subsequent bile leakage and hemorrhage. Antibiotics and liver supportive care are also essential part of treatment after surgery.
The treatment of large bowel injury is determined by several factors; the location and extent of the colon injury; the mode of injury; the general condition of the patient; intra-peritoneal soiling etc.
Primary repair of the injury with proximal colostomy is used for lesions of the rectum and recto sigmoid below the peritoneal reflexion. Injury of spleen is best managed by the immediate splenectomy and drainage of left subphrenic space. Occult rupture of spleen which occur about 10^15% of traumatic splenic involvement would require eventual splenectomy. Small intestinal injuries are most frequent in the upper jejunum near the ligament of treiz, but remaining portion of small bowel down to ileocecal junction are not the exceptional site of injury. It is treated with primary closure with debridement, resection with end-to-end anastomosis. On exploration of small bowel, its entire circumference and mesentery should be examined.
Injury of extra-hepatic biliary tract manifests bile peritonitis picture most of time, so that if the question arises, paracentesis is really valuable for the diagnosis. The treatment of gall bladder laceration is cholecystectomy. Biliary duct laceration are managed with primary repair with T-tube or primary end-to-end anastomosis or Roux-Y choledocho-jejunostomy. Patients with retroperitoneal hemorrhage should be explored promptly, if the following conditions are present. These are unstable vital signs, lowering Ht and Hb, rapid pulse and progressive peritoneal signs.
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KEYWORD
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