Spectrum of injuries and outcome following blunt trauma to the abdomen at a tertiary care centre in North India

INTRODUCTION

Blunt trauma abdomen (BTA) is defined as ‘damage to the abdomen and/or abdominal organs secondary to impact with a blunt (not penetrating) object or surface’. Blunt trauma that causes intra-abdominal injuries has been recorded since historical times. The abdomen can suffer from blunt trauma as an isolated injury or as a result of polytrauma, making it a common surgical emergency.

Road traffic injury remains the most common cause of blunt trauma to the abdomen, followed by a fall from height (FFH). In comparison to women, men are more likely to sustain traumatic injuries because they are the family breadwinners, more engaged in activities like driving, mechanical work, and aggressive behavior. They are also more likely to be under the influence of alcohol.

Clinical symptoms can take many different forms, including pain, nausea, vomiting, abdominal rigidity, and distension. Diagnosing BTA and its management is still challenging for a surgeon, and if diagnosed at the right time, prompt treatment can save the life of the patient.

Although the epidemiology of blunt trauma abdomen has been described in multiple studies, region-specific data are limited, and injury patterns, mechanisms ( road traffic injury, falls, assault), and resource availability vary between centers.¹ Diagnosing BTA can be very challenging. Focused assessment with sonography for trauma (FAST) and computed tomography (CT) are useful but can miss hollow viscus and other occult injuries. Morbidity and mortality increase because of delayed or missed diagnosis. These challenges and the shortage of regional studies are necessary to form relevant diagnostic pathways.

METHODOLOGY

The present study was conducted in the Emergency Surgical Ward, Jawaharlal Nehru Medical College, AMU, Aligarh, from December 2020 to November 2022 after obtaining the Institutional Ethics Committee approval.

RESULTS

In our study, the age group of more than 15 years was included. Among the 100 patients, the most common age group associated with blunt trauma to the abdomen was between 15 and 30 years, which is 46%. The middle-aged group between 31 and 40 was the second most associated with BTA. The demographic profile of the patients is summarized in Table 1.

The most common mode of injury was Road traffic injury, which is 68%, followed by fall from height (FFH), which is 17%. The various mechanisms of injury are presented in Table 2.

Out of 100 patients, the most common organ involved in blunt trauma to the abdomen was the spleen (32%), followed by the liver (20%). This was followed by injury to the small bowel, which was 16%, and mesenteric injury, which is 14%.

3 patients out of 100 sustained injury to the kidney and stomach. Five patients sustained injury to the bladder, and pancreatic injury was found in 2 patients.

Two patients were found to have adrenal gland injury, and prostate injury was found in 1 patient. The distribution of organ injuries is shown in Table 3.

In our study, 32 patients out of 100 underwent emergency surgical exploration, and the remaining 68 patients were managed nonoperatively. The overall management pattern of patients is illustrated in Figure 1.

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Figure 1: Management in BTA. BTA: Blunt trauma abdomen

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Out of 32 patients who suffered splenic injury, 5 patients underwent splenectomy (15.6%). Out of 16 patients who had small bowel injuries, 8 patients (50%) underwent primary bowel repair, four patients (25%) underwent resection and anastomosis, and 4 patients (25%) underwent resection and anastomosis along with stoma formation.

14 out of 32 patients were found to have AAST grade IV splenic injury. 11 patients had AAST grade III splenic injury, and three patients each had AAST grade II and grade V injuries, respectively. All patients with grade I, II, and III splenic injury were managed nonoperatively.

Out of 3 patients with grade V splenic injury, two patients underwent splenectomy, and one was managed nonoperatively. Angioembolization was done in one patient with AAST grade IV splenic injury, and the rest of the grade IV injuries were managed with NOM.

Pancreatic resection was done in 2 patients, and primary repair with modified Graham’s patch was done in 3 patients with gastric perforations who suffered injury from blunt abdominal trauma. Caecal perforation was present in 1 patient, who underwent right-limited hemicolectomy.

All of the 20 patients who had sustained liver injury were managed nonoperatively. The severity distribution of splenic and liver injuries based on AAST grading is depicted in Figures 2a and 2b.

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Figure 2: Severity of splenic injury (a) and liver injury (b) with blunt trauma to the abdomen. BTA: Blunt trauma abdomen.

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In our study, 17 patients had polytrauma. Head injury was the most common, followed by blunt trauma to the chest.

The percentage of mortality was found to be 11% in our study. Operative mortality rate accounted for 31.2 % (10 patients died of 32 patients who underwent operative management). Mortality rate was found to be 2.9% (2 out of 68 patients) who were managed non-operatively. 88 patients out of 100 were discharged satisfactorily, and one patient left against medical advice. The mortality pattern observed in the study is shown in Figure 3.

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Figure 3: Mortality pattern among patients with BTA. BTA: Blunt trauma abdomen, LAMA: Leave against medical advice

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Patients who were managed non-operatively had an average hospital stay of 6-8 days. Patients operated on without any postoperative complications had an average hospital stay of 10-12 days. Patients who had polytrauma and were operated on for blunt trauma to the abdomen needed postoperative intensive care unit (ICU) care, and their hospital stay was prolonged.

DISCUSSION

Males are more affected by blunt trauma to the abdomen. 80% of the patients in our study were males with a male to female ratio of 4:1. This is comparable to the study done by Mehta et al.² (79%) and 79.4% in study done by Fazili et al.³ and (90%) in the study done by Sreenidhi et al.⁴ and Suhas et al.⁵ Men predominate because they provide the majority of the income and engage in the majority of outside activities, including travel.

The majority of the patients (46%) in our study were between the ages of 15 and 30, which is comparable to the findings of Mehta et al⁵ (40%). The average age of our study was 34. The second most common age group was 31-40 years. It may be said that the majority of the casualties were from the working and adolescent population. This is because of the rash driving and ignorance of traffic rules by the young and adolescent population.

In our study, 68% of patients with blunt trauma to the abdomen had Road traffic injury, which was comparable with the study of Amuthan et al.⁶ Another study done by Curie et al.⁷ also shows that road traffic injury is the major cause of blunt abdominal injuries. A study done by Mehta et al.² shows 53% and Suhas et al.⁵ shows 61% cause, as the cause of road traffic injury. Modernization and the rise in vehicle use are the causes of road traffic injury. The likelihood of blunt trauma to the abdomen can be considerably decreased by preventing automobile accidents. The second most common mode of injury was a fall from height (17%), which is also close to the results of the research of Amuthan et al.⁶

In our study, the three primary radiological investigations used were chest X-ray, PA view, X-ray abdomen, erect and supine views, ultrasound, and contrast enhanced computed tomography (CECT) abdomen. All patients had X-rays and ultrasounds done since they were easy, rapid, and accessible. An X-ray of the abdomen in an erect position was more helpful in finding hollow viscus injury, such as small bowel and gastric perforation.

Contrast-enhanced CT is the diagnostic tool of choice for the evaluation of abdominal injury due to blunt trauma in hemodynamically stable patients. A CECT abdomen was done in hemodynamically stable patients with suspected solid organ injury and doubtful cases of hollow viscus injury. Because of its accuracy in detecting and grading injuries, CECT is pivotal in deciding whether a patient needs immediate surgery or can be managed non-operatively. Patients with hollow viscus injuries in whom a diagnosis had already been determined, as well as those with solid organ injuries who were hemodynamically unstable, did not get a CT scan.

Out of 100 patients, 98 patients presented with injury to intra-abdominal organs, and two patients had soft tissue injury. In our study, the spleen was the most common solid intra-abdominal organ injured; 32 patients out of 100 had splenic injury. Representative CT images of grade III and grade IV splenic injuries are shown in Figure 4a-4b. An example of a shattered spleen identified intraoperatively is shown in Figure 4c. The commonest injured organ in the four series was the spleen though the percentages are variable. 45.3% patients had splenic injury following blunt trauma to the abdomen in the study done by Parreira et al.⁸, and 53% splenic injury was seen in Mehta et al.⁵ study.

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Figure 4: Coronal section of CECT whole abdomen showing AAST (a) grade III (b) and grade IV splenic injury, respectively, in BTA. (c) Intraoperative image showing a shattered spleen following blunt trauma abdomen. CECT: Contrast enhanced computed tomography, AAST: American Association for the Surgery of Trauma, BTA: Blunt trauma abdomen.

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The second most common solid organ involved was the liver in our study. The CECT images of grade II and grade III liver injuries are shown in Figure 5a and 5b. The study done by Patel et al.⁹ shows the liver as the most common solid organ injured in blunt trauma to the abdomen, followed by the spleen. The small bowel was the most commonly injured hollow viscus (16%), followed by the urinary bladder (5%). Parreira et al.⁸ reported 5.3% injuries in the small intestine/colon. The most common site of hollow viscus injury was the ileum, followed by the jejunum, colon, and duodenum in the study done by Kurane et al.¹⁰ The most common retroperitoneal organ injured was the kidney in all series.

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Figure 5: Coronal section of CECT whole abdomen showing (a) AAST grade II (white arrow) and (b) grade III (black arrow) liver injury, respectively, in BTA. CECT: Contrast enhanced computed tomography, AAST: American Association for the Surgery of Trauma, BTA: Blunt trauma abdomen

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The most common symptom in our study was pain, and it was present in all cases, while 92.9% patients had pain as a common symptom in a study conducted by Mehta et al.² All the patients who presented with a case of blunt trauma to the abdomen complained of abdominal pain. In our study, tenderness was the most prevalent symptom, appearing in 98% of participants. Localized tenderness may also be a sign of a damaged organ. 26% of the individuals in our research were in hypovolemic shock. Shock is a sign of an intra-abdominal or retroperitoneal hemorrhage, which will kill the patient if it is not recognized and properly treated. In circumstances when the patient presents with unexplained hypotension without a CT scan, internal hemorrhage should be ruled out, and prompt intervention is to be done in order to save the life of the patient. Here, FAST provides immediate, portable, bedside imaging, making it crucial in the first-line imaging of hypotensive trauma patients.

NOM is an established and accepted management protocol for most BTA injuries. 68% patients with blunt trauma to the abdomen were managed non-operatively in our study, of which there were patients who had severe injury to intra-abdominal organs like spleen, liver, and kidney as diagnosed by CECT abdomen. This was comparable with the study done by Pandey et al.¹¹ Non-operative management was successful in these patients with proper monitoring, and thus laparotomy was avoided. Mehta et al.² show that 70% of splenic, liver, and renal injuries from BTA can be treated with NOM. Rahman et al.¹² showed that 53.52% of patients with solid organ injury were managed non-operatively. 84.3% of splenic injury was managed non-operatively in our study, while non-operative management was successful in 59.61% cases of splenic trauma in the study by Trehan V et al.¹³ NOM was successful in all isolated liver injuries. Renal injuries were treated successfully with non-operative management in our study. Five patients were found to have extraperitoneal urinary bladder injury following blunt trauma, and all were managed nonoperatively; the patients improved.

Angioembolization was done in one patient with grade IV splenic injury and was successful. Cherian et al.¹⁴ found that trans arterial embolization was quite successful at treating bleeding related to blunt trauma to the abdomen with minimal complications. All grades of liver injuries were managed by NOM.

There is a shift in trend towards non-operative management, which has been successful in our study and has avoided negative laparotomies and unnecessary increase in morbidity.

The control of hemorrhage, which relies on the grade, location, and severity of the organ/organs injured, is the primary concern in blunt trauma to the abdomen. Patients who were hemodynamically unstable even after adequate resuscitation with suspected solid organ injury and patients who had hollow viscus injuries such as small bowel and caecum with signs of peritonitis underwent surgical exploration. A total of 32 patients underwent emergency surgical exploration. This is comparable with the study done by Trehan V et al.¹³ where it was 39.9%. 5 out of 32 patients who had grade V splenic injury underwent splenectomy.

Small bowel perforation was present in 16 patients, of whom eight patients underwent primary repair. Primary repair of the mesentery (without bowel injury) was done in 5 patients. Resection and anastomosis were done in 4 patients with complete transection of bowel and mesentery. Mesenteric injuries encountered in the study, including hematoma and cut-off mesentery with bowel gangrene, are shown in Figures 6a and 6b. All the patients with gastric perforation were primarily repaired using the modified Graham’s patch technique. A right-limited hemicolectomy was done in one patient with caecal perforation.

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Figure 6: Intraoperative findings in (a) a case of mesenteric hematoma (black arrow) and (b) another case of cut off mesentery with bowel gangrene following blunt trauma abdomen.

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Delay in presentation, early diagnosis, identifying associated injuries, and delayed surgical intervention contribute to mortality in blunt trauma to the abdomen. In the current study, mortality was found to be 11%. A study done by Amuthan et al.⁶ shows a mortality of 10%. Out of the ten patients from the postoperative group, ten patients died during the recovery phase, the majority of them from hypovolemic shock, septicemic shock, and respiratory complications. Associated head injury, injury to the chest, and long bone fractures augmented the severity of injury and were a cause for mortality among these patients. A retrospective study done by Arumugam et al.¹⁵ shows that the most common cause of death in blunt abdominal injury is associated with traumatic brain injury. Two patients died before surgery while receiving NOM treatment. Two of them were initially treated in peripheral centers and were presented late with hypovolemic shock. Adequate resuscitation and early access to definitive trauma care are essential to save the patient. This demonstrates the drawbacks of cautious care, such as undetected injuries and delayed treatment.

Associated injuries are common in blunt trauma to the abdomen with polytrauma. Failure to recognize an extra-abdominal injury may contribute to the severity of the patient's condition. The current study shows head injury as the most common associated injury with blunt trauma to the abdomen, followed by blunt injury to the chest with single or multiple fractured ribs on one side or both. No neurosurgical intervention was done in patients who had associated head injury. All patients were managed nonoperatively. Intercostal tube drainage was done in cases of hemothorax following blunt trauma to the chest. Mehta et al.² show rib fracture in 20% of patients as the most common extra-abdominal injury. Overall hospital stay and morbidity were increased in patients with polytrauma.

In our study, postoperative complications were seen in 20 cases out of 32 cases operated. Hypovolemic shock was the most common complication seen, followed by septicemic shock. Shock-induced physiological derangements impair healing. ARDS, sepsis, and longer ICU stay were seen in patients with polytrauma. Delay in presentation causes irreversible shock and contamination, leading to postoperative complications.

The length of a patient’s hospital stay depends on the type of treatment they receive, such as operative or NOM, their condition before arrival or following an assessment, and any associated injuries. Patients who were managed non-operatively had an average hospital stay of 6-8 days. Patients operated on without any postoperative complications had an average hospital stay of 10-12 days. Patients who had polytrauma and were operated on for blunt trauma to the abdomen needed postoperative ICU care, and their hospital stay was prolonged. This was similar to the findings of Mehta et al.²

CONCLUSION

Blunt abdominal trauma poses a significant diagnostic and therapeutic challenge for every surgeon due to its variable presentation, rapid clinical deterioration, and often subtle early signs. Road traffic injury (RTI) remains the most common cause of BTA. An increase in the number of RTIs among young males signifies the need for road traffic awareness and traffic rule education. Timely primary intervention, proper resuscitation, and referral to a higher center in blunt trauma abdomen are crucial for definitive care and reducing the mortality. A high index of clinical suspicion, supported by appropriate imaging and investigations, remains essential for timely diagnosis and optimal management. Non-operative management is safe and effective in the majority of hemodynamically stable patients with solid organ injuries when accompanied by careful monitoring. Emergency surgical intervention is primarily indicated in patients with hollow viscus injuries or hemodynamic instability, while extensive reconstructive procedures should be avoided in unstable patients, emphasizing the role of damage control surgery. Careful evaluation of the retroperitoneum is crucial to identify occult sources of hemorrhage. The evolving trend toward selective, non-operative strategies has reduced unnecessary laparotomies and associated morbidity. Additionally, emerging treatment modalities such as angioembolization in advanced centers show a significant decrease in the need for operative intervention in high-grade solid organ injuries, contributing to improved patient outcomes and reduced morbidity and mortality.