Blunt abdominal injury: a review of 59 consecutive cases undergoing surgery

The universe of immune deficiencies in Crohn's disease: a new viewpoint for an old disease?

Crohn's disease (CD) is generally considered a multifactorial disorder, since different genetic and environmental factors are thought to play a role in its pathogenesis. Recently, genome wide linkage studies allowed to identify the association of several loci with the increased risk of CD, although it is still unclear how they interact with environmental factors in causing the disease. The fact that many CD-risk-related genes are involved in the function of phagocytes seems in agreement with the well known role of these cells in CD histopathology. Functional defects in cytokine production or in clearance of bacteria in CD patients have recently been reported. Growing evidence that CD could arise from primary phagocyte immunodeficiency is also coming from the study of cases with early onset in infancy. We review such evidences starting from selected cases and discuss the clinical implications of these findings.

Selective vascular occlusion with staged hemihepatectomy for blunt liver trauma

BACKGROUND

A 23-year-old man with extensive blunt trauma to the right lobe of the liver in whom adequate haemostasis could not be achieved by selective suturing and packing was encountered. Contributing factors to poor haemostasis included massive transfusion, hypothermia and acidosis.

METHODS

Hepatic haemostasis was achieved by selective intrahepatic ligation of the right hepatic pedicle and packing.

RESULTS

After resuscitation and stabilization in the intensive care unit, a right hemihepatectomy was performed 14 h later.

CONCLUSIONS

The present case describes a modification of the Pringle manoeuvre, termed 'selective Pringle manoeuvre'. This technique is a useful additional strategy for the management of uncontrollable bleeding in massive hepatic trauma.

Seventy cases of injuries of the small intestine caused by blunt abdominal trauma: a retrospective study from 1970 to 1994

BACKGROUND

Injuries of the hollow viscera are far less common in blunt abdominal trauma than in penetrating abdominal trauma. This article is a 25-year retrospective study of 70 patients with injuries of the small intestine caused by blunt trauma. All patients were treated surgically at the trauma hospital (Unfallkrankenhaus) in Graz. In our series, blunt abdominal trauma causing hollow viscus injuries occurred in conjunction with multiple trauma in 68.8% of cases. The overall mortality rate was 25.7%.

METHODS

The following methods were used for evaluating the intestinal injury: detailed history of the accident and examination of the patients (e.g., transverse abdominal bruise) diagnostic peritoneal lavage before 1984, abdominal sonography since 1984, computed tomography, and laboratory tests.

RESULTS

Prognosis and results depended partly on the general condition of the patient, as well as the timeliness of diagnosis and surgical management of the small bowel injury. Delays in diagnosis were common because of the overall condition of the patient, as well as the difficulty in establishing a definitive diagnosis by using current radiologic and serologic modalities.

CONCLUSION

It should be stated that the high mortality of small bowel injuries after blunt abdominal trauma justifies an aggressive approach to diagnosis and surgical treatment of these injuries. This article focuses on injury mechanisms and current concepts in diagnosis and the therapy of small intestine lacerations in blunt abdominal trauma.

Blunt abdominal injuries. Diagnostic peritoneal lavage, ultrasonography and computed tomography scanning

The diagnosis of blunt abdominal injuries is one of the most difficult problems in the management of trauma. There is now better understanding of the diagnostic facilities available. Guidelines regarding the use of diagnostic peritoneal lavage, ultrasonography, or computed tomography scanning should be available in the Accident and Emergency department.

CT scan in blunt abdominal trauma

CT scan has been used in blunt abdominal trauma with increasing popularity during the last decade. The sensitivity, specificity and accuracy of CT scan in blunt abdominal trauma have been reported to be very high. CT scan has been shown to eliminate the disadvantages of diagnostic peritoneal lavage (DPL) in the diagnosis of retroperitoneal organ injuries and when there are associated major pelvic fractures. This study describes the results of CT scan in 50 blunt abdominal trauma patients at the Chulalongkorn Hospital, Bangkok, Thailand. All patients had stable vital signs at the time of CT scanning although 36 per cent were in shock on arrival. In all, 34 per cent had associated pelvic fractures. Retroperitoneal organ injuries were suspected in 80 per cent. Of the patients, 34 per cent underwent exploratory laparotomies because of positive CT scan with three unnecessary operations. The sensitivity of CT scan to predict the necessity of operation is 100 per cent, specificity 92 per cent, accuracy 94 per cent, positive predictive value 82 per cent and negative predictive value 100 per cent. We conclude that CT scan is highly reliable in the management of blunt abdominal trauma, especially when retroperitoneal organ injuries are suspected or when there are associated major pelvic fractures. CT scan is also an invaluable tool in selected cases of non-operative management of hepatic trauma.

Post-traumatic, delayed rupture of the colon without identifiable cause

This paper reports the case of a male adult, 47 years old, with a gunshot wound to the right thigh, with no previous history of abdominal or cardiovascular disease, and a consistently satisfactory circulatory state on admission and thereafter. He showed signs of perforation of the caecum on the 10th day following admission. The explanation for this has been hard to find, and a search of the literature revealed no previous similar reported occurrence.

Rupture of diaphragm associated with spinal cord injury

A review of 1,007 patients treated a spinal injuries unit revealed 11 instances of rupture of the diaphragm. In five patients it took more than 48 hours before the ruptured diaphragm was diagnosed. The hazards of delay in diagnosis and treatment were highlighted by three instances of gastric perforation--two due to attempted pleural aspiration and one spontaneous. There is a need for the greater use of contrast radiology in the assessment of these patients.

Hepatic resection for trauma, tumour and biliary obstruction

Hepatic resection was performed in 37 patients. Fifteen emergency procedures were undertaken for blunt trauma and 16 patients had elective resection for hepatic tumour. A further 6 resections were performed for benign biliary tract obstruction. The importance of preoperative assessment and the indications for resection are discussed particularly in relation to resection for biliary obstruction. Operative procedures are outlined and the technique of extended left lobectomy is described in detail.

Equestrian injuries--a one year prospective study

A one year prospective study of equestrian injuries was carried out in an area where horse riding is a popular pursuit. 115 persons suffered injury--eighty females and thirty-five males of whom sixty were under fifteen years of age. No fatalities were recorded and there were 0.2 injuries per 100 rides. Most injuries were minor and to the musculo-skeletal system. Visceral and cerebral injuries were not common but the former were life threatening in all cases. It is concluded that young riders should be supervised.

Isolated perforations of the ileum and jejunum in blunt abdominal trauma

A report of ten cases of perforations of the ileum and jejunum from blunt abdominal trauma is presented. The perforation was the only injury in eight patients, while in two there were other visceral injuries. The perforations were single in seven patients and double in three. Simple closure was used in seven cases and resection in three. Of the three patients who were operated upon late, one died.

Intestinal injury due to non-penetrating abdominal trauma

Five cases of intestinal injury alone due to non-penetrating abdominal trauma are presented. The possible mechanisms of intestinal injury are discussed, together with the presentation, investigation and management of these cases.

Isolated mesenteric injury due to blunt abdominal trauma

Isolated injuries of the small bowel mesentery or mesocolon with subsequent bowel infarction due to blunt abdominal trauma are rare. Two cases are described: 1 involving the mesentery to the terminal ileum and 1 involving the transverse mesocolon and middle colic artery, both with bowel infarction. The modes of clinical presentation and management of patients with injuries to the mesentery, mesocolon and mesenteric vessels following blunt trauma are described.

Abdominal lavage in blunt trauma

A technique for abdominal lavage is described and was used to evaluate the abdomen of 671 multiple trauma victims. In 44 per cent (299 cases) there was a bloodstained return and these were regarded as positive. Patients with a positive result underwent exploratory laparotomy which revealed that 89 per cent had significant intra-abdominal trauma requiring a surgical procedure, 8 per cent had trauma which did not require any active surgical correction and 3 per cent had no abdnormal findings. Of all the lavages performed, there were 0-11 per cent false positive and 0-03 per cent false negative results. The value of the test in the context of multiple trauma is emphasized.