Pediatric Annals

Acute Abdominal Injuries in Children

James L Talbert, MD; Bradley M Rodgers, MD

Abstract

1 . Haller, J. A., Jr., and Talbert, J. L. (eds.). Surgical Emergencies in the Newborn. Philadelphia: Lea & Febiger, 1972.

2. Sinclair. M. C, Moore. T. O. and Asch. M. J. Penetrating abdominal injuries in children and adolescents. Am. Surg. 41 (1975), 342.

3. Salter, R. B. Care for the Injured Child. Baltimore: The Williams & Wilkins Company. 1975.

4. Haller. J. A., Jr.. and Talbert. J. L. Trauma and the child. In Ballinger, W. F., Il (ed.). Management of Trauma, Second Edition. Philadelphia: W. B. Saunders Company, 1973.

5. Morse. T. S. Renal injuries. Pediatr. Clin. North Am. 22 (1975). 379.

6. Mishalany, H. Repair of the ruptured spleen. J. Pediatr. Surg. 9 (1974). 175.

7. Stone. H. H. Major hepatic resections in children. J. Pediatr. Surg. 10 (1975), 127.

8. Stone, H. H., and Lamb, J. M. Use of pedicled omentum as an autogenous pack for control of hemorrhage in major injuries of the liver. Surg. Gynecol. Obstet. 141 (1975). 92.

9. Asch, M. J., Coran. A. G., and Johnston, P. W. Gastric perforation secondary to blunt trauma in children. J. Trauma 15 (1975), 187.

10. Vassey, L. E., et al. Traumatic gastric perforation in children from blunt trauma. J. Trauma 15 (1975), 184.

11. Talbert, J. L, and Felman, A. H. Identification and treatment of thoracoabdominal injuries in "battered children." South. Med. J. 58 (1970). 37.

12. Vollman, R. W., Keenan, W. J.. and Eraklis. A. J. Post-traumatic chylous ascites in infancy. N. Engl. J. Med. 275 (1966), 875.…

The abdomen is a common site of injury at all ages, but the incidence increases as the infant leaves the protective security of the crib and is exposed to the numerous environmental hazards of modern society. Even at birth, the sophisticated resuscitative techniques that have assured improved infant survival may, at the same time, produce intra-abdominal injury. Assisted ventilation may lead to gastric distention and rupture, while insertion of a thermometer or monitoring probe into the relatively short retroperitoneal rectal canal of a neonate incurs an increased risk of intra-abdominal perforation.1

In younger children, penetrating injuries of the abdomen may result from falls against sharp objects; in older children and adults, such wounds may be self-inflicted or a product of the "urban warfare" of our modern cities. In a recent series of 107 children and adolescents who underwent surgical exploration for penetrating abdominal trauma, 60 per cent of the injuries resulted from stab wounds and 40 per cent from gunshot wounds.2 Boys were affected more frequently than girls (4:1), and only 8 per cent of the patients were under 12 years of age. The incidence of multiple-organ injuries was significantly higher in patients sustaining gunshot wounds, and all significant morbidity and mortality were encountered in this group.

Blunt abdominal injury is the most common form of abdominal trauma and comprises approximately 2 to 5 per cent of all childhood accidents. A review of 200 patients from the Hospital for Sick Children in Toronto revealed that 75 per cent of these injuries occur in boys, with an increased incidence during periods of the year when outdoor activities are most popular.3 If the trauma was isolated to the abdomen, it resulted from a fall in 80 per cent of the cases. If multiple injuries were present, 60 per cent of the cases derived from traffic accidents. In 75 per cent of the total cases, rupture of the kidney, liver, or spleen was present; in 45 per cent of the patients there were serious associated injuries, including fractures in 25 per cent, head injuries in 20 per cent, and thoracic injuries in 15 per cent. In 10 per cent of the patients more than one intra-abdominal structure was injured.

The unique anatomy of the young child may render him especially susceptible to the effects of trauma. The developing skeleton is proportionately more flexible at this age and provides relatively limited protection for the viscera, which in older children and adults are normally shielded by the pelvis and lower rib cage. This problem is compounded by the relatively large size and the anatomic location of the liver, spleen, kidneys, and bladder. Because of the lack of adequate perirenal, omental, and mesenteric fat, cushioning of the intra-abdominal organs may be diminished. The thinness of the abdominal wall, the narrow anteroposterior diameter of the abdominal cavity, and the relatively broad costal arch of the young child invite a special propensity for intra-abdominal injury. Finally, concomitant congenital anomalies or disease of intraabdominal organs may be associated with an increased risk of injury.

DIAGNOSIS

Since the initial assessment of the traumatized child determines the direction of subsequent treatment, it is essential that this evaluation be precise and thorough. An exact description of the accident and the injuring force or object may provide important clues to the potential for serious intra-abdominal injury. Falls against sharp objects (such as the edge of a table or the handlebar of a bicycle), direct blows to the abdomen (such as a kick), or multiple injuries suffered in an auto accident may be associated with serious intraabdominal damage, no matter how insignificant the findings may appear on initial examination. If the injury is penetrating, the length and the type of instrument are important; in the case of gunshot wounds, the caliber of the missile, the type of shell, and the distance of the subject from the firearm all may provide important clues to the relative potential for injury and the type of treatment that may be required. In the case of the child who has been struck by an automobile, the speed of the vehicle, the site of initial impact, and the subsequent trajectory of the body - during which additional injuries may have been sustained - are all important aspects of the history that require thorough documentation. The amount of time that has elapsed between injury and arrival at the treatment center may also aid the physician in assessing the seriousness of the injury. In children, just as in adults, it is important to ascertain the presence of associated anomalies or illnesses that may increase the potential for injury or complicate the usual treatment regimen. Finally, in spite of the importance of an accurate and complete history, this information may be unobtainable in the comatose child or unreliable in the case of the "battered child."

The first step in examining the patient with suspected abdominal trauma, just as in other injuries in childhood, is a rapid overall inspection and assessment of the patient's condition. The presence of multiple injuries increases the potential for intra-abdominal trauma. Hypovolemic shock in the absence of an obvious source of external blood loss raises the question of hidden intrathoracic or intra-abdominal bleeding. In children, it is rare for head injuries, including scalp lacerations, or closed fractures of the extremities to produce sufficient blood loss to induce hypovolemic shock. Visible signs - such as scratches, hematomas, or contusions - may suggest a site of potential injury. Splinting of the thorax or abdominal musculature may provide an indication of serious underlying injury. Abdominal distention suggests acute gastric dilation, massive intraabdominal bleeding, or intestinal perforation. Evisceration may accompany extensive penetrating injuries to the abdomen and clearly indicates a need for surgical intervention.

Before proceeding with the physical examination, the physician should invest a few moments to win the confidence and trust of the child and thus assure his cooperation and enhance the validity of subsequent observations. Few tasks in clinical medicine are more challenging than attempting to examine the abdomen of an apprehensive, struggling child.4 The vital signs should be noted as a baseline for subsequent serial monitoring. Palpation and compression of the rib cage and pelvis may reveal evidence of fractures, which, in turn, suggest the possibility of injury to underlying intraabdominal organs. Light percussion of the abdomen may help in identifying peritoneal irritation. Evaluation may be assisted by allowing the child to place his hand beneath that of the examining physician. During auscultation over the abdomen, light pressure may be exerted and areas of tenderness further defined. Placement of an injured child in the parents' arms may encourage him to relax and may facilitate examination. Palpation of the abdomen and flanks may alert the physician to the presence of intra-abdominal masses or enlarged organs. The presence or absence of bowel sounds and their subsequent disappearance on serial monitoring may provide important clues as to the seriousness of intraabdominal trauma. Measurements of the abdominal girth at the level of the umbilicus should also be recorded.

Aspects of the treatment regimen and examination that will produce discomfort for the patient should be delayed, when feasible, until the initial evaluation has been completed. A rectal examination should be performed to rule out the presence of bleeding, pelvic masses, or fractures. When any question persists as to the possibility of serious injury requiring either immediate treatment or observation, an intravenous catheter should be inserted either percutaneously or by cutdown, preferably in the upper extremities or neck. Concomitantly, blood samples should be obtained for baseline studies and type and cross match. A nasogastric tube should be inserted to relieve gastric distention, to prevent possible vomiting and aspiration, to rule out the presence of upper intestinal bleeding, and to provide a potential avenue for subsequent roentgenographic examination of the upper gastrointestinal tract when indicated. Relief of gastric dilatation by insertion of a nasogastric tube will often result in a remarkable alteration in the abdominal physical findings, with immediate resolution of tenderness and guarding. A urinalysis is essential for complete evaluation of any patient suspected of intra-abdominal injury. An unconscious patient or a patient who is unable to void should be catheterized, especially in the presence of pelvic fractures when there is an increased risk of urethral or bladder perforation.

After the initial evaluation has been completed and the patient's condition stabilized, flat and upright x-rays of the chest and abdomen should be obtained, in a search for evidence of free air in the peritoneal cavity, an unsuspected hemothorax or pneumothorax, acute gastric distention, intra-abdominal masses, and rib, pelvic, or spine fractures. Small amounts of air under the diaphragm are best identified on the upright chest x-ray. If possible, these studies should be obtained in the emergency room. If transport of the child to a remote radiology facility proves necessary, every effort should be made to obtain all necessary studies in a single trip and to assure that adequate observation and care are provided throughout the patient's stay in the area. To avoid needless delay, the responsible surgeon and radiologist should consult regarding the radiographic findings and the need for further studies before the child leaves the radiology department.

The results of the initial evaluation may indicate a need for further, specialized studies. A child with multiple injuries, unstable vital signs, or evidence of respiratory insufficiency should have serial monitoring of central venous pressure or, in critically ill patients, insertion of a Swan-Ganz catheter for monitoring of the pulmonary wedge pressure. AU critically injured patients should have a Foley urinary catheter inserted for hourly monitoring of urine output. In some instances, arterial catheters should be inserted to facilitate continuous pressure and blood gas monitoring.

The role of paracentesis in the management of suspected abdominal trauma in children remains controversial. It is our belief that this procedure is unnecessary in the patient with clear signs of peritoneal irritation. The best indication for a "tap" is in the obtunded child who has a head injury and who may also have associated abdominal trauma. Unfortunately, a "negative tap" in an awake, alert child may provide the physician with a false sense of security while exposing the child to sufficient fright and discomfort to render further abdominal examinations increasingly difficult.

In cases of suggested intraabdominal injury, paracentesis should be performed bilaterally by percutaneous insertion of plastic intravenous catheters into the lower quadrants of the abdomen lateral to the rectus muscle, avoiding areas of scarring. If the initial aspirate is negative, the peritoneal cavity may be lavaged with 100 to 500 ml. of warm normal saline (depending on the age and size of the child). Paracentesis may prove especially helpful in the doubtful case in which initial evaluation has failed to define clear-cut indications for surgical intervention. Aspiration of blood, bile, or intestinal contents in such instances will confirm the need for immediate laparotomy.

Special x-ray studies may be indicated on the basis of the initial findings. In patients who are unable to sit for upright abdominal and chest x-rays, a lateral decubitus film is essential. In patients with penetrating injuries, the wounds of entrance and exit should be identified by radiopaque markers in order to provide a rough estimate of the course of the injuring instrument or missile. (Concomitantly, it must be recognized that missiles may ricochet and follow an erratic path on entering the body.)

In instances of suspected injury to the spleen or upper gastrointestinal tract, instillation of air via the nasogastric tube may prove helpful in defining a deformity of the greater curvature of the stomach by blood extravasated from a ruptured spleen or in identifying obstruction of the proximal gastrointestinal tract. In rare instances, meglumine diatrizoate (Gastrografin®) oral solutions may be instilled via the nasogastric tube to assist in defining duodenal or pancreatic trauma.

In patients with evidence of hematuria or suspected injuries to the urinary tract, emergency intravenous pyelography is required, not only to evaluate the potentially injured kidney but also to confirm the presence of a contralateral normal kidney. An emergency infusion pyelogram is performed by intravenous injection of 2 ml. of 25 per cent sodium diatrizoate (Hypaque·) per pound of body weight.5 A lateral view of the abdomen should be obtained during the course of this study to ascertain the presence of retroperitoneal hemorrhage. A voiding urethrogram should be included whenever possible to assess the urethra and bladder. In patients who have been severely injured or are in shock, visualization of the kidneys may not be feasible and the pyelogram should be delayed until the vital signs are stabilized or until bleeding has been controlled at the time of surgery. A urethrogram or cystogram should be obtained in suspected cases of urethral or bladder injury by instillation of 30 per cent sodium diatrizoate at a 30-cm. gravity pressure.

Intra-abdominal penetration of stab injuries can be confirmed by injection of 50 per cent sodium diatrizoate through a catheter inserted into the skin wound and secured with a purse-string suture. Any penetrating injury below the level of the nipple may affect the peritoneal cavity.

Selective arteriography is often helpful, especially when a ruptured solid viscus is suspected but cannot be verified by the studies outlined above. This procedure may be performed safely with percutaneous techniques, even in infants. Nuclear scanning techniques are becoming increasingly reliable and may offer assistance in defining injuries of the liver, spleen, or kidneys. Sonography also provides a new dimension for identifying masses or enlarged abdominal organs.

In most instances the presence or absence of significant intraabdominal injury can be confirmed on the basis of the initial evaluation, and the child can be either transferred directly to the operating room or discharged home. When the child is entrusted to the care of his parents, it is mandatory that the physician carefully explain the warning signs and symptoms of developing abdominal sepsis or hemorrhage and arrange for subsequent follow-up. The family physician should be notified as to the circumstances of the patient's injury and treatment, and a printed summary of the signs and symptoms of significant abdominal injury should be reviewed with the parents to assure their understanding and to provide documentation and protection for both the institution and the physician.

In a significant number of cases, however, the findings will remain inconclusive and the patient will require continued careful examination and monitoring. Once the vital signs have been stabilized and a tentative treatment regimen has been instituted, such patients should be moved to an intensive-care unit that specializes in the care of these children and is staffed by personnel skilled in recognizing subtle changes in clinical condition. The most reliable key to identification of serious intra-abdominal injury in such cases is careful, repeated physical examination of the patient by the same medical team over an extended period. Serial monitoring of the urine output, vital signs, hematocrit, white cell count, central venous pressure, serum amylase, and abdominal girth, in addition to recorded abdominal physical findings, are important in providing a complete picture of the patient's course and in identifying significant changes.

TREATMENT

An important element in the successful management of any seriously traumatized child, especially in the presence of potential multiplesystem injuries, is the designation of a single team of physicians who are skilled in the diagnosis and treatment of such patients and who can coordinate the various specialty groups that may be required for consultation. Only through this organization can continuity of care be assured.4

As in the management of all forms of serious traumatic injury, immediate attention must be directed towards establishment of adequate ventilation and cardiovascular function. Relief of respiratory distress may require insertion of an endotracheal tube and mechanical ventilatory assistance. When blood loss or shock is evident. Ringer's lactate solution should be infused immediately through an intravenous cannula inserted percutaneously or by venous cutdown in the upper extremities or neck. Hypovolemic shock represents a loss of 25 to 50 per cent of the circulating blood volume. The blood volume of a young infant approximates 10 per cent of the total body weight, with a gradual decrease to approximately 7 per cent of the total body weight in the adolescent. In such patients, a bolus of Ringer's lactate solution equal to one-quarter of the total blood volume should be administered as rapidly as possible for initial resuscitation. If the blood pressure returns to normal and does not fall again, blood transfusion will not be required. If the blood pressure remains low, however, a second bolus of 10 ml. per pound should be given rapidly, followed by 10 ml. per pound of whole blood. Once normal blood pressure has been restored and the patient's vital signs have been stabilized, surgical management can be undertaken. Abdominal exploration is best accomplished through a midline incision, which provides immediate and relatively bloodless access to the abdominal cavity while permitting wider exposure by extension of the incision superiorly and interiorly when necessary. Limiting access to the upper abdomen on the assumption of an isolated injury to the liver or spleen is an invitation to frustration. It is essential that the entire abdominal cavity, including the retroperitoneal duodenum, be examined thoroughly at the time of exploration.

The technique of tube gastrostomy may prove especially helpful in the management of young children when it is anticipated that prolonged postoperative gastrointestinal decompression may be required or when the presence of multiple injuries or serious head trauma will impede oral feedings. A gastrostomy not only assures optimum decompression of the gastrointestinal tract but also provides a safe, reliable route for subsequent institution of intestinal alimentation.

SPECIFIC INTRA-ABDOMINAL INJURIES

Spleen. The spleen is the most common intra-abdominal organ to be injured by closed abdominal trauma, and a ruptured spleen is the most common source of intraperitoneal bleeding. A few children bleed so rapidly and massively from splenic injuries that immediate surgery is mandatory. Such children are usually brought into the emergency department in shock, and after urgent resuscitation the abdomen becomes distended with blood. In a few instances, patients who are undergoing surgical correction of other injuries will, while under anesthesia, develop unexpected hypotension, hypovolemia, and abdominal distention. The presence of a ruptured spleen should be strongly suspected in these cases. The child with splenic injury usually has evidence of superficial injury to the left abdominal and chest wall and will manifest left upper-quadrant pain and tenderness. Older children may develop discomfort in the left neck and shoulder as a result of diaphragmatic irritation. Blood loss may be indicated by signs of hypovolemia and falling hematocrit. Two cardinal signs of intraperitoneal bleeding are abdominal distention and tenderness, as confirmed by repeated abdominal examination and girth measurements.

In some cases, the diagnosis will remain obscure and the indications for exploration inconclusive. In these instances the use of paracentesis, sonography, splenic scans, or arteriograms may prove helpful in defining the presence or absence of splenic injury. The presence of leftsided rib fractures, pulmonary contusion, pleural effusion, or renal damage, as confirmed by radiographic studies, should also suggest a coexisting splenic injury (Figure 1). Surgical intervention is clearly indicated in the patient with significant continuing blood loss. However, because of the documented role of the spleen in providing immunologic defense against infections in infants and children, conservative management of less serious splenic injuries has become increasingly popular.6 In regard to the patient who has stable vital signs with no evidence of continuing blood loss, some pediatric surgeons favor prolonged, cautious observation. The danger in such cases, of course, is the potential for delayed rupture of a subcapsular splenic hematoma, but this complication appears to be extremely rare in children. Even in cases in which limited splenic injuries are identified at the time of surgery, conservative management is warranted, with an effort to suture limited capsular tears or to tamponade with omental pedicle grafts. If splenectomy proves necessary in a child under five years of age, the patient should be maintained postoperatively on prophylactic antibiotic therapy in order to minimize the risk of fulminant, overwhelming infections with gram-positive organisms.

Liver, gallbladder, and biliary tract. The liver is the second most frequently injured organ in closed abdominal trauma. Like the spleen, the liver is more susceptible to trauma in children than in adults because of its larger size and the diminished protection afforded by the resilient rib cage. All degrees of injury may be encountered, from small subcapsular hematomas and superficial tears to deep lacerations and avulsions of entire segments of the liver. Hepatic rupture in the newborn may be the source of massive intraperitoneal hemorrhage as a result of birth trauma and failure to correct clotting deficits by prophylactic administration of vitamin Kj . In older children the association of shock, right upper-quadrant abdominal tenderness and rigidity, and right shoulder and neck pain suggests hepatic injury.

As with splenic injuries, minor degrees of hepatic trauma may be managed conservatively. In most instances, however, exploration and identification of the site and extent of damage are warranted. Hepatic lacerations may be sutured or packed, as seems appropriate. Major avulsed segments of the liver require resection. In children, massive bleeding is encountered more frequently as a result of liver injuries than from splenic trauma and requires immediate exploration with rapid restoration of blood loss and control of bleeding. In these cases it is important that a reliable route for fluid and blood administration be established through the upper extremities or neck, since compression or clamping of the inferior vena cava may be required in order to achieve successful control of the bleeding site. Optimally, adequate blood for massive replacement should be available before the abdomen is opened, since release of the tamponading effect of the closed peritoneal cavity can result in a precipitous drop in blood pressure. An excellent review of the technique of major hepatic resection for management of trauma has been presented recently by Stone, from the surgical service of Grady Memorial Hospital in Atlanta.7 In a series of 31 children under 16 years of age who underwent major hepatic resection, approximately half of the patients required treatment for trauma. The overall mortality in this series was 13 per cent, and two of four children subjected to 90 per cent resection survived. Clearly, when modern techniques for intraoperative and postoperative support are employed, extensive hepatic resections are feasible in these young patients.

Figure 1. Abdominal trauma resulted in injury to the kidney and spleen in this patient. A: On intravenous pyelography there was obvious rupture of the lower pole of the left kidney with extravasation of contrast material. Indentation of the greater curvature of the stomach suggested enlargement of the spleen (arrows). Selective renal (B) and celiac (C) arteriography confirmed rupture of the kidney and spleen.

Figure 1. Abdominal trauma resulted in injury to the kidney and spleen in this patient. A: On intravenous pyelography there was obvious rupture of the lower pole of the left kidney with extravasation of contrast material. Indentation of the greater curvature of the stomach suggested enlargement of the spleen (arrows). Selective renal (B) and celiac (C) arteriography confirmed rupture of the kidney and spleen.

A recent report by Stone and Lamb has documented the use of pedicled omentum as an autogenous pack for control of hemorrhage from major injuries of the liver.8 This technique is predicated on the fact that most hepatic injuries produced by closed trauma represent tears along the intersegmental and intralobular planes and involve disruption of the fragile and unsupported hepatic veins that normally pass between lobes and segments. The hepatic triads comprising the hepatic artery, portal vein, and bile ducts are usually preserved intact. Since bleeding in these cases represents retrograde hemorrhage from the open hepatic veins at a pressure equal to that within the vena cava, a viable pack of omentum, usually based on the right gastroepiploic vessels, has been found sufficient to fill the traumatic crevice in the liver and produce hemostasis. The liver edges are then sutured, and sump drainage is instituted. Experience with the use of this technique in 37 patients has confirmed its reliability.

A late and often overlooked consequence of liver trauma is traumatic hematobilia. This complication usually appears within four to six weeks following liver trauma and results from the development of a posttraumatic connection between the biliary and vascular systems. Characteristically, just when these children appear to have recovered from their initial trauma, they experience a sudden onset of biliary colic (with or without jaundice), followed by severe upper gastrointestinal bleeding. Hepatic scans and angiography are helpful in substantiating this diagnosis, and the treatment of choice is either selective arterial ligation or hepatic lobectomy.

The occurrence of biliary tract injuries in children is relatively rare. Penetrating injuries are encountered most often, usually in the gallbladder, and they require cholecystectomy. We have also treated two children with delayed inflammatory strictures of the common bile duct that resulted from blunt abdominal trauma and required surgical correction. In both cases, long-term follow-up has confirmed a complete relief of symptoms.

Figura 2. The presence of free intra-abdominal air following gastric perforation can be detected (A) by the air-contrast outline of the falciform ligament on the supine roentgenogram (arrows) and (B) by the presence of massive amounts of free air beneath trie diaphragm on the upright roentgenogram.

Figura 2. The presence of free intra-abdominal air following gastric perforation can be detected (A) by the air-contrast outline of the falciform ligament on the supine roentgenogram (arrows) and (B) by the presence of massive amounts of free air beneath trie diaphragm on the upright roentgenogram.

Gastrointestinal tract. Rupture of a hollow gastrointestinal organ appears to occur in 11 to 18 per cent of patients sustaining serious blunt trauma to the abdomen. Although gastric perforation in children is extremely rare, several recent reports have documented its occurrence and the difficulty of its recognition.9,10 The child who has ingested a meal before suffering blunt abdominal trauma appears to be especially susceptible. Because of the extensive peritoneal contamination that follows, early diagnosis and treatment are important in decreasing the mortality and morbidity resulting from this type of injury. The presence of massive amounts of free intraperitoneal air should always suggest the possibility of gastric perforation (Figure 2).

Immediate perforation of the duodenum may occur when acute compression of the air- or fluidcontaining viscus produces an intraluminal pressure exceeding 14 mm. Hg. The duodenum is a functional closed loop, limited proximally by the pyloric sphincter and distally by the ligament of Treitz. The most common site of perforation or intramural hemorrhage is at the junction of the second and third portions of the duodenum. Since the perforation is usually retroperitoneal, there may be no contamination of the abdominal cavity and the initial signs and symptoms may be minimal. Perforation is signified on the abdominal x-ray by the presence of retroperitoneal air or by extravasation of water-soluble contrast media (meglumine diatrizoate) administered through the nasogastric tube (Figure 3). Because of difficulties in diagnosis, delays in identification and treatment are frequent and the reported mortality of this condition has been relatively high.11

Ischemic necrosis and delayed rupture of the bowel wall may also result when a severe abdominal blow crushes the duodenum or intestinal segment against the vertebral column. If the perfpration is limited, debridement of the intestinal wall can be accomplished and the defect closed transversely. In more extensive injuries, it may be necessary either to employ the technique of serosal patch or to close the proximal and distal ends of the affected segment and to bypass the area of injury with a gastrojejunostomy.

Figure 3. The presence of intestinal perforation following a blow to the abdomen was confirmed in this child with equivocal physical findings by extravasation of radiopaque contrast media into the retroperitoneal tissues (arrow).

Figure 3. The presence of intestinal perforation following a blow to the abdomen was confirmed in this child with equivocal physical findings by extravasation of radiopaque contrast media into the retroperitoneal tissues (arrow).

An injury that is rare, but encountered most often in young children, is intramural duodenal hematoma.11 A description of this entity was first published in the 1950s, and cases have subsequently been reported with increasing frequency. In most instances, bleeding has appeared to be primarily intramuscular or submucosal and has often resulted from surprisingly insignificant degrees of trauma. The seemingly minor trauma of running into the edge of a table or falling against the handlebars of a bicycle can classically produce this lesion. The exact reason why children appear more susceptible to this injury than adults remains unclear, but it may be related to an improved vascular supply (resulting in bleeding rather than necrosis) or to the special anatomic configuration of the child's costal arch, which is somewhat higher and wider than that of the adult, exposing the duodenum and rendering it more susceptible to injury. The onset of symptoms can be gradual, and there may be a significant lag between the time of trauma and the development of pain or vomiting. As with subdural hematomas, subsequent degradation of hemoglobin may increase osmotic pressure and produce further expansion of the lesion. A concomitant pancreatic injury may be sustained at the time of initial trauma, or pancreatitis may ensue with progressive obstruction of the duct. In these circumstances, elevations of bilirubin, amylase, and lipase may be observed. The diagnosis of intramural duodenal hematoma can be confirmed radiographically by contrast studies, which identify either a typical "coil spring" appearance or complete obstruction of the intestinal lumen (Figures 4 and 5).

Figure 4. A: Epigastric trauma was followed by gastric distention and progressive elevation of the serum amylase in this patient. B: Instillation of radiopaque contrast media into the stomach confirmed obstruction of the duodenum as it crosses the spine (arrow). An intramural hematoma of the duodenum was evacuated surgically, and the patient's symptoms rapidly resolved.

Figure 4. A: Epigastric trauma was followed by gastric distention and progressive elevation of the serum amylase in this patient. B: Instillation of radiopaque contrast media into the stomach confirmed obstruction of the duodenum as it crosses the spine (arrow). An intramural hematoma of the duodenum was evacuated surgically, and the patient's symptoms rapidly resolved.

In less serious injuries, conservative management with gastrointestinal decompression, intravenous fluid therapy, and careful clinical observation can be employed until the hematoma resolves. The major indications for surgery include early development of symptoms, elevation of serum amylase, suspicion of duodenal rupture, and failure to respond to nonsurgical therapy. It is important that the surgeon not be misled as to the extent of injury by the dusky, hemorrhagic, edematous appearance of the duodenum. In most cases, simple incision of the superficial layers of the duodenal wall and complete evacuation of the hematoma will suffice. Instillation of a diluted solution of methylene blue dye through an indwelling nasogastric tube will again assist in ruling out concomitant perforation. The retroperitoneal area may be drained postoperatively, but drainage of the hematoma cavity itself should be avoided.

Injuries to the small bowel are rarer than injuries of solid intra-abdominal organs, occurring in only 5 per cent of all intra-abdominal trauma. They result from sudden, localized trauma to the abdominal wall or abrupt deceleration producing tears at the points of fixation of the intestine to the posterior peritoneum (i.e., ligament of Treitz and ileocecal valve). Signs of peritonitis usually herald intestinal perforation. In these instances, physical examination reveals a tender, distended abdomen with diminished bowel sounds. The diagnosis is confirmed by upright radiographs of the abdomen and chest, documenting the presence of free air beneath the diaphragm. The surgical treatment of damaged small bowel is usually resection and anastomosis.

Colon injury in children is relatively rare except in instances of penetrating trauma. Unlike highvelocity military injuries, uncomplicated colon injuries from stab wounds or low-velocity missiles may be debrided and closed directly. In cases resulting from high-velocity missiles or in which there is extensive tissue damage and peritoneal contamination, exteriorization of the damaged colonic segment is preferable. When exteriorization is not feasible, as in the case of rectal injuries, a proximal defunctioning colostomy may be required.

Pancreas. Pancreatic injuries occur in 1 to 2 per cent of cases with significant intra-abdominal trauma. Serum amylase determinations should be obtained routinely for diagnostic screening of all abdominal trauma in children, although a normal value does not exclude the possibility of pancreatic injury. Cases with transient elevation of the serum amylase and evidence of milder degrees of pancreatic injury may respond to nonsurgical supportive care. Persistent elevation or progressive rise in serum amylase for three to four days following injury suggests the development of traumatic pancreatitis and possible pseudocyst formation.11 This finding, in association with progressive evidence of peritoneal irritation, substantiates a need for surgical exploration. Contusions or lacerations of the pancreas in the absence of ductal tears may be treated by simple suture of the pancreatic capsule and external drainage. Avulsed segments of the pancreas should be treated by distal pancreatectomy and closure of the proximal duct and gland with nonabsorbable sutures. In rare instances, extensive, devitalizing injuries of the duodenum and head of the pancreas may require pancreaticoduodenectomy.

If surgical intervention is required early in the course of pseudocyst formation, external sump drainage may be necessary because of the anatomic location or immaturity and excessive thinness of the cyst wall. A significant recurrence rate has been documented with external drainage, however, and further surgery may be necessary. In cases of chronic or recurrent pseudocyst, the wall is usually sufficiently thick to allow internal drainage either directly into the stomach by cystogastrostomy or by a Roux-en-Y cystojejunostomy (Figure 6). If the anatomic location of the cyst is favorable, dependent drainage through Roux-en-Y jejunal loop is preferred. In rare circumstances, when the cyst is localized in the tail of the pancreas, complete excision may prove feasible.

Figure 5. The presence of an intramural duodenal hematoma was confirmed in this "battered child" by evidence of partial intestinal obstruction and the typical "coil spring" appearance of the duodenum (arrow). This patient's symptoms resolved with nonsurgical management.

Figure 5. The presence of an intramural duodenal hematoma was confirmed in this "battered child" by evidence of partial intestinal obstruction and the typical "coil spring" appearance of the duodenum (arrow). This patient's symptoms resolved with nonsurgical management.

Figure 6. This child, who had undergone an exploratory laparotomy for blunt abdominal trauma (A), was referred for evaluation of an enlarging abdominal mass, which, on radiopaque contrast study of the upper gastrointestinal tract (B), proved to be a pancreatic pseudocyst- The patient was successfully managed with a cystogastrostomy and has remained asymptomatic during a six-year follow-up.

Figure 6. This child, who had undergone an exploratory laparotomy for blunt abdominal trauma (A), was referred for evaluation of an enlarging abdominal mass, which, on radiopaque contrast study of the upper gastrointestinal tract (B), proved to be a pancreatic pseudocyst- The patient was successfully managed with a cystogastrostomy and has remained asymptomatic during a six-year follow-up.

Urinary trad. Renal injury frequently accompanies abdominal trauma in childhood and should be suggested by the development of pain and tenderness in the region of the costovertebral angle and by identification of red cells in the urine. The quantity of blood in the urine does not necessarily reflect the extent of injury, but the absence of hematuria practically excludes severe injury to the kidney or lower urinary tract except in instances of total avulsion of the ureter. A flank mass may be palpable or definable by sonography. The presence of pelvic fractures should suggest the possibility of injury to the bladder and urethra. These patients may manifest massive hematuria and pain on micturition, or they may exhibit anuria and suprapubic swelling. A drop of blood at the external meatus should also arouse suspicion of urethral injury. If the urethra has been avulsed from the bladder neck, digital examination of the rectum will reveal a boggy mass and a highriding bladder or prostate. Perineal ecchymosis is commonly encountered in cases of straddle injury to the urethra, as may occur when a child slips while walking along the top of a fence or railing. In the severely traumatized child or the child who is unable to void promptly, a urinary catheter should be inserted immediately. If the catheter encounters resistance, it should not be forced, since rupture of the urethra may be present.

A plain radiograph of the abdomen may demonstrate an enlarged kidney or haziness of the psoas shadow. An infusion pyelogram should be obtained in all patients with hematuria as soon as the vital signs are stable.5 Reduction in the amount of contrast visualized on the injured side and compression of the collecting system without extravasation are characteristic of renal contusion. Such injuries usually heal without either surgery or prolonged bed rest. Extravasation of contrast material beyond the renal capsule signifies disruption of the collection system, the parenchyma, and the renal capsule (Figure 1). In most instances, emergency exploration of a damaged kidney is not required and surgery is best delayed for a day or two following injury. Operation is required in only 20 to 25 per cent of children with hematuria, and in only 10 per cent of these cases will total nephrectomy be indicated. Bilateral visualization of contrast material implies intact renal vessels. Failure to identify contrast material on the injured side demands immediate investigation by renal scanning, retrograde pyelography, or arteriography. Kidneys deprived of blood supply by vascular injury may be salvaged if recognized and treated promptly.3

Some authors recommend routine excretory pyelograms in all cases of serious abdominal injury. In these patients, associated renal damage may go unrecognized preoperatively without such studies, and verification of a normally functioning kidney is essential before a direct attack is made on the injured organ.

During convalescence from a renal injury, serial pyelograms should be obtained at intervals to detect complications, such as strictures due to scar tissue or atrophic changes in the kidney. These patients should also be monitored for the development of hypertension. Ureteral injuries in children are extremely rare and may be indicated by extravasation of contrast media on the excretory pyelogram. A voiding cystourethrogram as a component of an excretory pyelogram or a retrograde cystogram will assist in identifying injuries of the bladder and urethra. Insertion of a catheter and splinting of the damaged urethra may prove feasible immediately following injury, although suprapubic catheter drainage may also be required.

Pelvis and retroperitoneum. Children who are run over or struck by moving vehicles are particularly susceptible to pelvic and retroperitoneal injuries. Profuse hemorrhage from the thin-walled pelvic veins not only is life threatening but also may prove extremely difficult to control by surgery. The developing bony pelvis in the child is less rigid than the pelvic ring in the adult and provides a lesser degree of protection for the contained viscera. Just as the young, flexible rib cage can bend and rupture the spleen, the young pelvis may undergo distortion without fracture. Injuries to the bladder, urethra, vagina, or rectum may ensue. The shock that accompanies severe pelvic fractures is predominantly hemorrhagic rather than neurogenic, and it is important to institute immediate transfusion until the hypovolemia is corrected and adequate circulation re-established. Large amounts of blood (comparable with 10 units in the male adult) can be extravasated routinely into the retroperitoneal space in extensive pelvic injuries. Severe disruption of the sacroiliac joints may produce concomitant damage to the adjacent iliac artery and sciatic nerve (Figure 7). Absence or impairment of the femoral pulse or sensation in the distal lower extremity suggests such injuries. Associated damage to the urinary tract, vagina, or rectum must be considered in such patients.

In cases of limited, undisplaced pelvic fractures without associated injury, the treatment is bed rest for 10 days and gradual return to full activity. A special challenge may be presented by the child with progressive retroperitoneal bleeding from extensive pelvic injuries or from paraspinal injuries resulting in tears of the lumbar and pelvic vessels. In the absence of any evidence of injury to intra-abdominal organs that might necessitate surgical exploration, the management of these cases should be supportive, with replacement of blood loss and reliance on tamponading of the vessels by the contained clot. Exploration of a massive retroperitoneal hematoma may lead to persistent intra-abdominal bleeding, which is almost impossible to control. In such instances, utilization of the MAST garment* can prove lifesaving (Figure 7).

Figure 7. As the result of being struck on the left side by an automobile, this nine-year-old boy sustained (A) extensive pelvic fractures (arrows), partial paralysis of the left lower extremity as a result of damage to the sciatic nerve, aid (B) disruption of the left external iliac artery (arrow). Because of evidence of progressive vascular insufficiency in the distal left leg, the segment of damaged vessel was bridged by an autograft of the left internal iliac artery. The patient subsequently developed massive hemorrhage from an infected retroperitoneal hematoma, which spontaneously ruptured and drained externally. Direct surgical control appeared impossible under these circumstances, but bleeding was controlled successfully by application of a MAST garment.

Figure 7. As the result of being struck on the left side by an automobile, this nine-year-old boy sustained (A) extensive pelvic fractures (arrows), partial paralysis of the left lower extremity as a result of damage to the sciatic nerve, aid (B) disruption of the left external iliac artery (arrow). Because of evidence of progressive vascular insufficiency in the distal left leg, the segment of damaged vessel was bridged by an autograft of the left internal iliac artery. The patient subsequently developed massive hemorrhage from an infected retroperitoneal hematoma, which spontaneously ruptured and drained externally. Direct surgical control appeared impossible under these circumstances, but bleeding was controlled successfully by application of a MAST garment.

COMPLICATIONS

Serious intra-abdominal injury is associated with a relatively high incidence of postoperative sepsis, and abscess should be suspected in any patient with a delayed onset of sepsis following injury to the liver, spleen, or intestine. Sonography, liver-lung scans, contrast studies of the gastrointestinal tract, and radioactive gallium scans may help to define the location of these abscess pockets.

In a few cases, chylous ascites may follow serious intra-abdominal injury.12 Conservative management of these patients with a diet containing medium -chain triglycerides and high protein, repeated paracenteses for relief of symptoms, and intravenous administration of plasma and albumen may achieve spontaneous resolution. When the ascites persist, however, exploration for identification of a ruptured lymphatic duct should be undertaken before the patient's condition deteriorates to the point where operation becomes excessively hazardous.

It is not unusual for patients exposed to serious trauma, as in all catastrophic illnesses, to have an increased incidence of upper gastrointestinal bleeding. This complication is particularly common in children who have associated head injury. Such bleeding may develop from stress ulcers, trauma to the lower esophagus and stomach from an indwelling nasogastric tube, or abnormalities of clotting factors resulting from prolonged absence of oral alimentation in association with antibiotic treatment and failure to administer prophylactic vitamin K1. When the bleeding results from ulceration of the esophagus, stomach, or duodenum, irrigation of the stomach with iced saline every one to two hours may provide control. If feasible, steroids and aspirin should be discontinued in these patients and 1-2 ounces of antacid placed into the stomach every few hours. If the bleeding persists and surgical intervention is required, the bleeding point should be identified and sutured if at all possible. The procedure of pyloroplasty, vagotomy, and drainage via a large-caliber gastrostomy tube has proved curative in all children in whom we have encountered this problem. Finney pyloroplasty has proved especially helpful in the management of children who have sustained extensive ulceration and damage to the duodenum, since it allows suture closure of a large defect while assuring patency of an outflow tract from the stomach into the duodenum.

BIBLIOGRAPHY

1 . Haller, J. A., Jr., and Talbert, J. L. (eds.). Surgical Emergencies in the Newborn. Philadelphia: Lea & Febiger, 1972.

2. Sinclair. M. C, Moore. T. O. and Asch. M. J. Penetrating abdominal injuries in children and adolescents. Am. Surg. 41 (1975), 342.

3. Salter, R. B. Care for the Injured Child. Baltimore: The Williams & Wilkins Company. 1975.

4. Haller. J. A., Jr.. and Talbert. J. L. Trauma and the child. In Ballinger, W. F., Il (ed.). Management of Trauma, Second Edition. Philadelphia: W. B. Saunders Company, 1973.

5. Morse. T. S. Renal injuries. Pediatr. Clin. North Am. 22 (1975). 379.

6. Mishalany, H. Repair of the ruptured spleen. J. Pediatr. Surg. 9 (1974). 175.

7. Stone. H. H. Major hepatic resections in children. J. Pediatr. Surg. 10 (1975), 127.

8. Stone, H. H., and Lamb, J. M. Use of pedicled omentum as an autogenous pack for control of hemorrhage in major injuries of the liver. Surg. Gynecol. Obstet. 141 (1975). 92.

9. Asch, M. J., Coran. A. G., and Johnston, P. W. Gastric perforation secondary to blunt trauma in children. J. Trauma 15 (1975), 187.

10. Vassey, L. E., et al. Traumatic gastric perforation in children from blunt trauma. J. Trauma 15 (1975), 184.

11. Talbert, J. L, and Felman, A. H. Identification and treatment of thoracoabdominal injuries in "battered children." South. Med. J. 58 (1970). 37.

12. Vollman, R. W., Keenan, W. J.. and Eraklis. A. J. Post-traumatic chylous ascites in infancy. N. Engl. J. Med. 275 (1966), 875.

10.3928/0090-4481-19761001-07

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