12 Abdominal Emergencies

Harsh K. Desai, MD; Christine M. Leeper, MD; and Kevin Garrett, MD

CHAPTER KEY WORDS

Blunt abdominal trauma
Hollow viscus injury
Solid-organ injury

CHAPTER SCENARIO

An 18-year-old male was elbowed in his left upper quadrant while playing soccer at a tournament several hours from his home. He continued to play and returned home at the conclusion of the game, but presented to the hospital 5 hours later with increasing abdominal pain, nausea, and weakness. His vital signs included blood pressure 98/54, pulse 80, oxygen saturation 100%, and respiratory rate 20. On examination, he was pale, diaphoretic, and had moderate tenderness to palpation in the left upper quadrant. A bedside ultrasound showed free fluid in the abdomen (Figure 12-1). Two large-bore intravenous catheters were placed, and 2 L of crystalloid fluid was administered with improvement in blood pressure. He underwent a computed tomography scan of his abdomen and pelvis with contrast, which revealed a splenic laceration in the lower pole of the spleen, active contrast extravasation from a branch of the splenic artery, and moderate hemoperitoneum (Figure 12-2).

SCENARIO RESOLUTION

The patient was transferred to a trauma center, where he underwent exploratory laparotomy and splenectomy (Figure 12-3). No other injuries were identified, and the patient was admitted to a monitored surgical floor. He recovered uneventfully and was discharged to home on post-trauma day 4, at which time he was eating a regular diet, ambulating, and performing all activities independently. He was instructed to resume daily activities gradually and return to cardio training in 3 to 4 weeks. He was cleared for weight lifting and sports contact after 8 weeks.

INTRODUCTION

Abdominal pain in athletes has a broad differential diagnosis. Pain may be an indication of life-threatening injury (eg, a splenic laceration), acute illness (eg, appendicitis), or more benign causes (eg, soft tissue bruising or muscle cramping). Evaluation of the athlete with abdominal pain should include a focused history regarding pain characteristics (eg, onset, duration, migration, and alleviating or exacerbating factors), antecedent trauma, and associated symptoms (eg, fever, vomiting, and weakness). Examination of the abdomen includes inspection for signs of trauma (eg, ecchymosis, abrasions, and lacerations) as well as superficial and deep palpation to assess for tenderness or peritonitis. If there is concern for significant injury, 911 should be activated to expedite evaluation in the appropriate setting. Athletes should refrain from eating or drinking prior to medical evaluation, and medical professionals should withhold pain medications to allow for a reliable physical examination.

Figure 12-1. Bedside ultrasound demonstrates free fluid within the abdomen adjacent to the kidney and liver.

Figure 12-2. CT scan of the abdomen demonstrates splenic injury.

Figure 12-3. Gross pathology demonstrates splenic laceration post-splenectomy.

Survival is improved when injured patients receive care at a designated trauma center—whether adult, pediatric, or combined—as compared to a non-trauma center. Further, pediatric patients have increased survival when cared for at designated pediatric trauma centers.1–3 Although most patients without serious injury can be evaluated and cared for in their local medical centers, they may be stabilized and transferred to a specialized center if they have significant injury mechanism, significant injury burden (eg, multiple long-bone fractures, polytrauma, amputation, spinal cord injury, spine fracture, severe head, polytrauma), or if they require specialist services at a tertiary care center.⁴

Solid-Organ Injury

Evaluation

Solid-organ injury is common in athletes after significant blunt abdominal trauma. The spleen is the most commonly injured solid organ (25% to 39%), followed by the liver (15% to 37%), kidney (19% to 25%), and pancreas (7%).⁵ While splenic injury is more common than hepatic injury, damage to the liver is responsible for most fatal solid-organ injuries and can result in significant hemorrhage and massive blood loss. Solid-organ injury should be suspected based on physical examination findings and injury mechanism. Injury mechanism, such as abrupt deceleration, impact from the handlebar of a bicycle or all-terrain vehicle, or trauma from a direct blow to the abdomen, should raise suspicion for intra-abdominal injury.

Determining which patients need a CT scan is an area of active research interest, particularly in adolescents and young adults. The desire to limit radiation burden should be weighed against the risk of missing significant intra-abdominal injury. Patients with evidence of abdominal wall or torso trauma on physical examination, with complaints of abdominal pain or presence of abdominal tenderness, vomiting, abnormal laboratory studies (eg, alanine aminotransferase and aspartate aminotransferase > 200/125, elevated amylase/lipase, 100 renal plasma clearance on urinalysis), gross hematuria, or a positive bedside ultrasound should undergo additional imaging with contrasted CT scan if hemodynamically stable versus fluid resuscitation and/or operative intervention if hemodynamically unstable. Patients without these signs and symptoms are at low risk for intra-abdominal injury and can likely be observed without additional imaging or intervention.⁶

Management

Immediate operative intervention is indicated in patients with peritonitis or hemodynamic instability. If a trial of nonoperative management is attempted, failure of this strategy is signified by worsening abdominal examination, ongoing blood transfusion requirements, or hemodynamic instability.7 Surgical intervention for splenic injury typically involves a total splenectomy, although other alternatives include partial splenectomy or splenorrhaphy. Hepatic injury can sometimes be controlled with cautery, application of hemostasis agents, and drainage. Nonanatomic resections or formal lobectomies are required less often. Kidney injury requires operative intervention for patients with hemodynamic instability, expanding retroperitoneal hematoma, vascular pedicle injury, urinomas, or major renal vascular injury.⁴ Pancreatic injury is uncommon, and optimal management is debated among experts (Figure 12-3). For blunt pancreatic injuries, major factors guiding management decisions include the presence of ductal injury and its location (ie, proximal vs distal). In the setting of duct injury, options include partial pancreatectomy for distal duct injuries and conservative interventions (eg, closed suction drainage and endoscopic stenting) for proximal ductal injuries.⁸

In patients who are unstable, surgical management often includes a damage control strategy. Surgical bleeding and gross fecal contamination are addressed expeditiously, packs are placed to tamponade coagulopathic bleeding, temporary closure of the abdomen is performed, and patients are stabilized and resuscitated in the intensive care unit prior to return to the operating room for definitive management of injuries and abdominal closure.^9–10 After splenectomy, patients should be vaccinated against pneumococcus, haemophilus, and meningococcus to reduce the risk of overwhelming postsplenectomy sepsis.

Of note, management of children and adolescents with solid-organ injury differs dramatically from management of adult patients with similar grade of injury. Even when high-grade injuries are present, solid-organ injuries are typically successfully managed nonoperatively in young people with serial abdominal examinations, serial hematocrit testing, bowel rest, and bed rest.⁶

Hollow Viscus Injury

Intestine

Hollow viscus injuries (15%) involve the jejunum, duodenum, colon, and stomach, in decreasing order of frequency.⁵ Injuries can include bowel perforation or tearing, bowel wall hematoma, and mesenteric tears that may devascularize the bowel and result in progressive ischemia or necrosis. The diagnosis of intestinal injury can be challenging, as a patient’s symptoms, such as nausea, pain, and malaise, may be mild, delayed, and nonspecific. Further, both ultrasound and CT scan procedures are less sensitive for intestinal injury compared to solid-organ injuries. Therefore. clinicians must have a high index of suspicion in patients with a direct blow to the abdomen, a deceleration mechanism (eg, seat-belt injury) issue, or a handlebar injury.¹¹ Physical examination findings include tachycardia and abdominal wall bruising (ie, seat-belt sign).^12–13 Symptoms may include abdominal pain, peritonitis, and bilious emesis. Radiologic imaging is often normal, but nonspecific indicators may include free fluid or mesenteric edema or stranding. Laboratory findings include elevated lipase, white blood cell count, or lactate. Operative intervention is indicated in patients with peritonitis or in patients with a high suspicion for injury based on the presence of the previously described factors.

Bladder

Up to 85% of the time, injury to the urinary bladder is most commonly associated with a blunt mechanism of injury, with motor vehicle collision being the predominant mechanism.¹⁴ The bladder is located near the pelvic floor posterior to the pubic symphysis and anterior to the vagina in women and rectum in men, separated from these organs by the prevesical space of Retzius. The peritoneum covers the dome, which is most vulnerable to injury as it rises into the peritoneal cavity with distension. Up to 90% of patients with such injuries will have concomitant pelvic fractures. Injuries are classified as extraperitoneal (60%) or intraperitoneal (30%). Up to 10% of patients will have a combined injury.¹⁵ Patients most commonly present with gross hematuria, along with lower abdominal pain. Intraperitoneal injuries that may be initially missed can present with ileus, inability to void, azotemia, acidosis, electrolyte imbalances, and peritonitis.

In the hemodynamically stable patient, diagnosis may be made with retrograde cystography using either plain film or CT scan. CT cystography is most commonly used today and involves filling the bladder with 300 cc of water-soluble contrast via a Foley catheter¹⁶ (see Figure 12-4). Management of injury is based on location and complexity. Simple extraperitoneal injuries are managed using catheter drainage alone for 2 to 3 weeks, with cystography performed prior to removal. Complex extraperitoneal injuries, such as open pelvic fractures, concurrent rectal or vaginal injury, or bladder neck injury, often require surgical repair. Intraperitoneal injuries always warrant surgical repair, as these are often large, and leakage of urine risks sepsis and peritonitis.¹⁷

Appendicitis

The appendix is located at the inferior tip of the cecum, deriving its blood supply from the appendiceal branch of the ileocolic artery. It works to secrete immunoglobulins, particularly immunoglobulin A. Appendicitis—inflammation and infection of the appendix—has a lifetime occurrence of 7%, with one-third of all cases occurring in those below age 18 years. The highest incidence occurs in males age 10 to 14 and females age 15 to 19. The most common cause of appendicitis is mechanical obstruction with an appendicolith. Other causes include hyperplasia of lymphoid tissue and neoplasm.18 Luminal obstruction results in progressive inflammation and pressure due to bacterial overgrowth and accumulation of secretions. The most commonly involved bacteria include Escherichia coli and Bacteroides fragilis. The distension of the appendix stretches visceral nerve fibers, resulting in the vague epigastric pain that is often the first sign of appendicitis. When inflammatory changes affect the serosa, there is extension to the parietal peritoneum, resulting in localized right lower quadrant pain.