Blunt Abdominal Trauma: Injury to the Epigastrium - Lieberman's

43 Pages·2010·4.15 MB·English

by  Maria Nemethy

Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Blunt Abdominal Trauma:
Injury to the Epigastrium
Mária Némethy, Harvard Medical School, Year III

Gillian Lieberman, MD
Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Blunt Abdominal Trauma (BAT)
• Trauma is the leading cause of death in the
United States in persons under 45 years of

age
• Because it primarily affects the young, trauma
causes more lost years of productive life than

cancer and cardiovascular disease combined
• Blunt trauma accounts for 2/3 of all injuries

• Majority of abdominal injuries are due to blunt
trauma; 10% of trauma fatalities are due to

abdominal injury
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Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Mechanisms of injury
• Compression: direct blow or against a fixed object
(seat belt, spinal column)

– Generally results in tears or subcapsular hematomas in
solid organs

– Increased intraluminal pressure can cause rupture of
hollow organs

• Deceleration: stretching and linear shearing
between fixed and movable structures

– Rupture of supporting elements at junction between fixed
and free segments of organs

– Thrombosis of vessels contained within supporting
elements

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http://www.emedicine.com/EMERG/topic1.htm
Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Injuries resulting from blunt
abdominal trauma
• Common:
– Liver – most commonly injured in all abdominal trauma
(blunt and penetrating)

– Spleen – most commonly injured organ in blunt trauma
– Kidney – increasing frequency (increased detection)

– Bladder (extraperitoneal)

• Rare :
– Pancreas  Adrenal
– Bowel  Bladder (intraperitoneal)

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Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
First, a brief review of retroperitonal
anatomy.
Note the crowding of the numerous soft
organs in the epigastrium, with little
bony protection. Unlike small bowel,
these organs are fixed in place, and
so cannot move out of the path of
blunt traumatic forces.
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Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Abdominal Retroperitoneum
Inferior vena cava Abdominal aorta
Pancreas
Duodenum
(retroperitoneal)
Left kidney
Right kidney
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Netter FH. Atlas of Human Anatomy, 2nd ed.
Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Epigastric region

IVC
Abdominal
aorta
Right adrenal
Left adrenal
Right kidney
Pancreas
Duodenum
Left kidney
Transverse colon
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Netter FH. Atlas of Human Anatomy, 2nd ed.
Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Options for evaluating BAT
• Plain film

– Difficult to evaluate soft-tissue injury
– Ma y reveal free intraperitoneal air or signs of
bowel obstruction

• Deep peritoneal lavage

– Rapid detection of hemoperitoneum
– Inv asive
– Ris k of visceral and vascular injury
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Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Options for evaluating BAT
• CT – gold standard for BAT evaluation
– MDCT: high-resolution images and reconstructions
allow improved detection and management of soft-

tissue injury, hemorrhage, etc

• Ultrasound – increasing use
– Safe for unstable patients; decreased costs
– Limitations: fluid-filled bowel versus hemoperitoneum;

extraperitoneal fluid versus intraperitoneal fluid; cystic

masses can look like fluid collections; obesity

• MRI – not used in initial evaluation of BAT

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Mária Némethy, HMS III
Gillian Lieberman, MD
November 2004
Our Patient
JO, a 23-yr-old woman kicked in the
stomach by a horse
● Imaging at outside hospital

suggested pancreatic injury; JO was
transferred to BIDMC for more
complete evaluation
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