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Nonpenetrating Injuries of the Abdomen
N onpenetrating Injuries of the Ahdomen GROVER C. PENBERTHY, M.D., F.A.C.S. * CHARLES R. REINERS, M.D. **
THE nature and extent of surface injuries and injuries to the extremities are usually obvious; those involving the abdominal viscera without penetration of the abdominal wall are less likely to be recognized early. This type of injury is generally classed among the relatively infrequent lesions. The increasing number of motor vehicle accidents, which so often account for these injuries, make them a problem that occasionally confronts every practitioner of surgery. The diagnosis is often rendered far more difficult by the fact that they are, not uncommonly, associated with other, more obvious injuries which tend to distract attention from the abdomen. The history of the nature of the injury is highly important since the etiologic factor plays a major role in the diagnosis of the probable extent of intra-abdominal injury and in the formulation of a plan of treatment. In our experience, automobile accidents were the most frequently encountered mode of injury. Another type of accident often causing visceral injury of this nature occurs when a man is caught between a truck and a loading platform. On the other extreme, such seemin~ly slight trauma as a blow with a fist or falling against the edge of a table may result in serious visceral injury. Because of the mobility of most of the abdominal viscera, trauma applied slowly is less likely to cause rupture of a viscus than are sudden, sharp blows. A distended hollow viscus is more likely to rupture than one that is empty, while a hollow viscus which is the site of a pathological process, such as ulcer or diverticulum, might be expected to rupture easily. However, such a locus of a rupture is actually rare. 1
* Clinical Professor of Surgery, Wayne University College of Medicine, Detroit; Consultant in Surgery, Detroit Receiving Hospital and Dearborn Veterans Hospital. ** Assistant Instructor in Surgery , Wayne University College of Medicine, Detroit Resident in Surgery, Detroit Receiving Hospital. 1179
1180
Grover C. Penberthy, Charles R. Reiners
Viscera lying in a fixed position near the spinal column or the lumbar musculature are particularly susceptible to injury, since the traumatizing force can readily crush them against these firm structures. Consequently the kidneys, pancreas and duodenum are frequent sites of injury.2 Rupture of the pancreas may be overlooked and small tears may result in the formation of a cyst to be discovered at some time remote from the accident. The head of the pancreas or that portion lying over the spleen is most likely to suffer from crushing injuries. CASE 1. H. H., a man aged 29, was kicked in the abdomen during a fight with a policeman. He was initially hospitalized in another institution for 2 months, during which time he had pain and swelling in the abdomen and was operated on twice, for what reason he did not know. Following release from the hospital, he had persistence of cramplike pain which became especially marked one-half hour after eating. This pain was not relieved by food or alkali. He was studied in the hospital for three months after his injury, but no cause for his difficulty was found. One year after the injury he was again admitted because of gradual increase in the amount of pain. He also vomited occasionally and had periods of diarrhea. On examination there was a firm, movable mass in the upper abdomen which was tender to palpation. Pancreatic cyst was thought to be the most likely diagnosis and at operation one was found which contained 1~ gallons of foul-smelling fluid having an amylase content of 381 units per 100 cc. This was marsupialized.
Comment. In injuries of the upper abdomen, the possibility of injury to the pancreas should be borne in mind. This case illustrates the point that vague symptoms resulting from pancreatic injury may be difficult to diagnose. In this case one year elapsed following injury before the true diagnosis was made evident by the development of a cyst large enough to be palpated.
Tearing injuries of the small bowel are most likely to occur near the points of fixation of the bowel such as near the ligament of Treitz, near the ileocecal valve, or at the root of the mesentery. Also the small bowel tends to rupture more easily on its antimesenteric border, this site presumably being weaker than the mesenteric side. Hollow viscera appear to be more readily ruptured by a blow with a ~harp object, while the solid viscera are more readily injured by a blow with a broad, crushing object. In spite of the protected position of the liver and spleen under the costal cage, they are not infrequently injured. In these cases, however, there are often associated fractures of the lower ribs or evidence of trauma over these ribs which should serve to direct attention to the underlying viscera. Fracture of the pelvis and particularly the pubic rami should direct attention to the urinary bladder and urethra.
Nonpenetrating Injuries of Abdomen
1181
All intra-abdominal hollow viscera are not completely intraperitoneal and this may cause some confusion in diagnosis if not properly considered. The most notable of the extraperitoneal hollow viscera are the duodenum, ascending colon, descending colon and bladder. Rupture of these viscera in their retroperitoneal portions does not produce the classical signs of peritoneal irritation, and they may therefore go unrecognized. The diagnosis of serious damage to intra-abdominal structures is not usually possible immediately after the accident. In this stage the severity of the pain is often less than the severity of the abdominal lesion. The same is often true of tenderness to palpation. In these cases a short period of vigilant observation may be of value. We stress the importance of keeping this period of observation short. The mortality in these cases bears a direct relationship to the length of time operative intervention is delayed. A severe blow to the abdomen usually causes a great deal of disturbance immediately and soreness in the abdomen is likely to persist for some time even when no serious intra-abdominal injury is present. Conversely, the fact that the patient appears to recover quickly from a severe blow to the abdomen does not rule out a serious intra-abdominal injury, since quite often the patient will appear to recover from the immediate effects of trauma to the abdomen, but will develop signs of visceral injury later. This has been justly labeled the "period of illusion,"3 and makes close observation imperative. The following is an illustrative case report. CASE II. L. G., aged 45, a maintenance man, was engaged in sawing a piece of wood which caught in the blade and was thrown against his abdominal wall. At first he did not think he was hurt, but soon he became nauseated and noticed severe pain about the genitals and rectum with pain later in the abdomen. He was admitted to the hospital 5 hours after the accident. Physical examination showed no surface evidence of trauma, but the abdominal wall was rigid. Operation 7% hours after the accident showed a tear of the ileum.
Comment. If such a patient is seen soon after the injury he should be kept under observation or advised to report immedia~ely after the first evidence of abdominal pain or nausea, weakness or shortness of breath on exertion. It is not unusual for a ruptured hollow viscus to result in delayed signs and symptoms several hours after the accident. Those from ruptured solid viscera may be delayed for days or weeks. EARLY TREATMENT OF SHOCK
The urgent need for the early and vigorous treatment of shock should not need to be emphasized. If shock is present when the patient is first seen, therapy should be started immediately, since it will not interfere
1182
Grover C. Penberthy, Charles R. Reiners
with other diagnostic procedures, a'1d can, in fact, be carried out simultaneously with them. An infusion of glucose in saline should be started at once. Blood transfusion should be performed as soon as possible, and as frequently as necessary. While blood is being obtained hemoglobin, hematocrit and white blood cell determinations can be made. Some index of the state of the patient can be gained from these initial determinations. They are also essential as a baseline for comparison with future determinations. A word of caution is necessary concerning the use of morphine or other narcotics before the diagnosis is established. Although morphine is acknowledged to be an excellent drug in the treatment of shock, it may hopelessly confound the diagnostic picture by masking the early signs of peritoneal irritation, pain, tenderness, and so on. Valuable time is lost thereby, and a successful outcome is further jeopardized. It is our practice to withhold morphine until such time as the decision for or against operation is established. The surgeon must use his discretion in this matter. The practice of avoiding narcotics in cases of actual or suspected cerebral injury should be stressed. In cases of early profound shock without evidence of external bleeding of sufficient degree to account for the shock, intraperitoneal bleeding must be presumed. 1£ the abdominal signs and symptoms agree with this presumption, the decision to operate must not be delayed. Ample supplies of compatible whole blood should be on hand at the time of operation. In our experience 1500 or 2000 cc. should be considered the minimum amount to have readily available. A Levin tube should be placed in the stomach early when there is evidence of intra-abdominal injury. This is valuable for several reasons. The aspirated material may contain blood. This is presumptive evidence of injury to the stomach or duodenum. A Levin tube is of therapeutic value in the presence of acute gastric dilatation which is often found in these cases, particularly in children. It is also prophylactic against the development of distention if paralytic ileus occurs, since most of the distention in these cases is from swallowed air. Aspiration of the gastric contents reduces the anesthetic hazard and is a technical aid to the surgeon in cases which subsequently come to laparotomy. ROENTGENOLOGIC SIGNS OF INJURY
The x-ray is an important adjunct to diagnosis. In all instances supine and upright flat films which include the diaphragm are essential. A chest film is also quite helpful. Recognition of fractures of the ribs, pelvis or lumbar spine and transverse processes confirms the occurrence of a severe type of trauma and directs attention to the nearby structures as probable sites of injury. The early diagnosis of rupture of the diaphragm with
Nonpenetrating Injuries of Abdomen
1183
herniation of abdominal viscera into the thorax is of extreme importance, and can be made with certainty only by x-ray studies. The presence of free air under the diaphragm is diagnostic of perforation of some portion of the gastrointestinal tract, and is an absolute indication for early laparotomy. Free air in the retroperitoneal tissues is diagnostic of perforation of the gastrointestinal tract in one of the retroperitoneal areas, in the absence of subcutaneous emphysema from a chest injury. If a chest x-ray is made, this should not be a source of confusion, especially if the x-rays are made early before the subcutaneous emphysema becomes generalized. The areas where the bowel is retroperitoneal and where such rupture can occur are notably the duodenum, ascending colon and descending colon, as previously mentioned. The loss of the psoas shadows is an indication that there is free peritoneal fluid. Localized masses or shadows in any region may indicate local hematomas or fluid collections. This is of particular importance when noted in the left upper quadrant, since it sometimes is seen in rupture of the spleen. Paralytic ileus with air-fluid levels in the small bowel may result directly from the initial trauma, or it may indicate a spreading peritonitis, and should be interpreted with caution. Acute gastric dilatation as demonstrated by a very large air bubble in the left upper quadrant may produce a clinical picture very hard to differentiate from more serious forms of intra-abdominal injury. These cases show marked tenderness, and spasm in the epigastrium with considerable distention. This condition, when severe, may produce or aggravate systemic shock. Fortunately, a ready solution is at hand in the Levin tube, as mentioned earlier. Attention is called to the danger of placing too much faith in one negative laboratory or x-ray finding. Most of the above-mentioned x-ray findings are of importance only when positive. All too often their absence is misleading, as the following case will illustrate. CASE III. L. M., aged 46, a male factory worker, was admitted to the hospital 1;!1 hours after having received a blow of moderate crushing force to the abdomen when caught between a bench and a conveyor belt. Immediately after the blow he was short of breath, but had no severe pain and did not lose· consciousness. A right inguinal hernia which had been present for 5 years became tender and more prominent after the injury. The hernia was easily reducible. The patient was admitted for observation complaining only of dull drawing pain in the lower abdomen. On examination, his blood pressure was 130/90, temperature 98.2°F., pulse 74, respiration 20. There was generalized abdominal tenderness, most marked in the right lower quadrant; slight distention; diminished peristaltic sounds; no rebound tenderness, rigidity or muscle spasm. The right inguinal hernia was tender on palpation but was easily reducible. Rectal examination was negative. Blood count was 15,400 white cells with 87 per cent polymorphonuclears, 6 per cent lymphocytes and 7 per cent monocytes. Urinalysis was negative.
1184
Grover C. Penberthy, Charles R. Reiners
Chest x-ray was negative. The flat plate of the abdomen was reported as showing "No evidence of ruptured viscus. No evidence of intestinal obstruction." The patient's condition remained essentially the same during his first day in the hospital. On the second day his abdominal distention increased as did his abdominal pain. Bowel sounds diminished and it was noted that he had had no bowel movement and had not passed gas since admission. Temperature rose to 101.3°F. and he began to vomit. A Miller-Abbott tube was passed and began to drain dark brown fluid. Temperature returned to normal. On his fourth day his temperature spiked to 104°F. The Miller-Abbott tube was draining large amounts of foul-smelling, black fluid. There was no localizing abdominal tenderness. On the evening of the fourth day laparotomy was performed and an avulsion of a large segment of the small bowel mesentery was found. A resection of the gangrenous portion of the small bowel was done, with end-to-end anastomosis of the small bowel. Immediately after the procedure the patient's condition seemed satisfactory, but soon began to deteriorate. His temperature rose to 105°F. and he died soon after in peripheral vascular collapse. ~- Comment. There are several features of this case which merit special
attention. We notice again the absence of severe pain immediately after the accident, but the subsequent development of both pain and tenderness. The false sense of security that was engendered by the negative x-ray report based on the fiat plate of the abdomen was certainly contributory to the tragic outcome in this case. It is far better to rely on the clinical picture of the patient and his progress or failure to improve during a short period of observation than to credit undue importance to the results of any single negative examination or test. CASE IV. S. W., aged 39, was admitted to the hospital 4 days after he had received a beating in a fight. He came to the hospital because of progressively severe pain in the lower left chest which was aggravated by coughing or deep breathing. He also felt weak, and had had one episode of syncope. On examination his blood pressure was 90/70 and pulse 80. There was pallor of the conjunctivae, marked tenderness and crepitation over the tenth rib in the posterior axillary line, and some tenderness in the left upper quadrant, although not marked. Bowel sounds were normal. Hemoglobin was 7.7 grams. Urine was negative. X-ray of the chest revealed a fracture of the tenth rib posteriorly, but was otherwise negative. The report on a flat plate of the abdomen was, "No evidence of abnormal mass within the left upper quadrant which is usually seen with a large hemorrhage." The tentative diagnosis was retroperitoneal hematoma. Abdominal tap was performed, but no blood was obtained. The patient was transfused with 1500 cc. of blood, and pressure rose to 130/80. On the second hospital day, laparotomy was performed and the patient was found to have a large tear of the anterior surface of the spleen with approximately 2000 cc. of old blood within the peritoneal cavity. Splenectomy was performed. The patient went into shock on the operating table, but responded to rapid transfusion after the splenic pedicle had been clamped. Recovery was uneventful.
Comment. Splenic injury should always be suspected in fractures of the tenth, eleventh or twelfth ribs on the left side. If fractures in this
Nonpenetrating Injuries of Abdomen
1185
area are accompanied by unexplained anemia, it is presumptive evidence of rupture of the spleen. If this anemia is progressive it is an incontrovertible indication for immediate laparotomy. Notice that in this case the absence of a mass in the left upper quadrant on x-ray examination was temporarily misleading, as was the failure to recover blood on attempted diagnostic paracentesis. After a seemingly satisfactory initial response to conservative therapy this patient had a second hemorrhage two days later which could well have been fatal. These belated hemorrhages have been known to occur after an asymptomatic interlude as long as four to six weeks from the initial injury. This patient failed to demonstrate the radiation of pain to the left shoulder which is so often a helpful diagnostic aid. Fractures of the pelvis and pubic rami are a mandate for investigation of the urinary bladder and urethra. A catheter should be passed if the patient is unable to void. If the urine contains no evidence of blood it is presumptive evidence that the bladder is intact. If, in addition, a measured amount (200 to 250 cc.) of sterile saline can be injected into the bladder and then completely recovered, the bladder may be considered intact. If, however, there is blood in the urine or saline escapes from the bladder, it is best to do cystography. An x-ray film of the lower abdomen and pelvis is made after having filled the bladder with 20 cc. of Diodrast diluted with 200 cc. of sterile saline. Injection of 200 cc. of air may accomplish the same purpose. The site of extravasation can usually be localized, which will aid materially in its discovery at operation. SUMMARY
1. It is important to take a complete history of the alleged accident and to make a physical examination, including x-rays as indicated. 2. Early and vigorous treatment of shock which is important can be continued while the diagnostic work-up is being done. 3. The use of morphine in cases of suspected intra-abdominal injury is contraindicated until the diagnosis has been definitely established. There may be an exception, depending upon the circumstances and the judgment of the physician. 4. Frequent observation with frequent re-examination is essential if the diagnosis of intra-abdominal injury is to be made early. Early operation is vital because of the direct relationship between mortality rate and the time interval between injury and operation. 5. The patient known to have suffered severe trauma to the abdomen and under observation with persistent abdominal pain, spasm and tenderness with or without nausea or vomiting should be suspected of having
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Grover C. Penberthy, Charles R. Reiners
a perforation of an abdominal viscus. If the signs persist for six hours, an exploratory laparotomy is indicated. 6. We wish finally to emphasize the necessity for early surgical exploration of the injured abdomen before every evidence that warrants this act is at hand, because irreversible complications may appear with unheralded speed. These can best be dealt with before their occurrence, not after they hold the center of the stage. REFERENCES 1. Penberthy, G. C. and Benson, C. D.: Injuries to the Abdomen in Industry. Am. J. Surg. 74,' 346, 1947. 2. Penberthy, G. C.: Acute Abdominal Injuries. Surg., Gynec. & Obst. 94: 626 1952. 3. Cogley, J. P.: The Traumatic Abdomen. J. Iowa State M. Soc., Nov., 1951 p. 451.
THE nature and extent of surface injuries and injuries to the extremities are usually obvious; those involving the abdominal viscera without penetration of the abdominal wall are less likely to be recognized early. This type of injury is generally classed among the relatively infrequent lesions. The increasing number of motor vehicle accidents, which so often account for these injuries, make them a problem that occasionally confronts every practitioner of surgery. The diagnosis is often rendered far more difficult by the fact that they are, not uncommonly, associated with other, more obvious injuries which tend to distract attention from the abdomen. The history of the nature of the injury is highly important since the etiologic factor plays a major role in the diagnosis of the probable extent of intra-abdominal injury and in the formulation of a plan of treatment. In our experience, automobile accidents were the most frequently encountered mode of injury. Another type of accident often causing visceral injury of this nature occurs when a man is caught between a truck and a loading platform. On the other extreme, such seemin~ly slight trauma as a blow with a fist or falling against the edge of a table may result in serious visceral injury. Because of the mobility of most of the abdominal viscera, trauma applied slowly is less likely to cause rupture of a viscus than are sudden, sharp blows. A distended hollow viscus is more likely to rupture than one that is empty, while a hollow viscus which is the site of a pathological process, such as ulcer or diverticulum, might be expected to rupture easily. However, such a locus of a rupture is actually rare. 1
* Clinical Professor of Surgery, Wayne University College of Medicine, Detroit; Consultant in Surgery, Detroit Receiving Hospital and Dearborn Veterans Hospital. ** Assistant Instructor in Surgery , Wayne University College of Medicine, Detroit Resident in Surgery, Detroit Receiving Hospital. 1179
1180
Grover C. Penberthy, Charles R. Reiners
Viscera lying in a fixed position near the spinal column or the lumbar musculature are particularly susceptible to injury, since the traumatizing force can readily crush them against these firm structures. Consequently the kidneys, pancreas and duodenum are frequent sites of injury.2 Rupture of the pancreas may be overlooked and small tears may result in the formation of a cyst to be discovered at some time remote from the accident. The head of the pancreas or that portion lying over the spleen is most likely to suffer from crushing injuries. CASE 1. H. H., a man aged 29, was kicked in the abdomen during a fight with a policeman. He was initially hospitalized in another institution for 2 months, during which time he had pain and swelling in the abdomen and was operated on twice, for what reason he did not know. Following release from the hospital, he had persistence of cramplike pain which became especially marked one-half hour after eating. This pain was not relieved by food or alkali. He was studied in the hospital for three months after his injury, but no cause for his difficulty was found. One year after the injury he was again admitted because of gradual increase in the amount of pain. He also vomited occasionally and had periods of diarrhea. On examination there was a firm, movable mass in the upper abdomen which was tender to palpation. Pancreatic cyst was thought to be the most likely diagnosis and at operation one was found which contained 1~ gallons of foul-smelling fluid having an amylase content of 381 units per 100 cc. This was marsupialized.
Comment. In injuries of the upper abdomen, the possibility of injury to the pancreas should be borne in mind. This case illustrates the point that vague symptoms resulting from pancreatic injury may be difficult to diagnose. In this case one year elapsed following injury before the true diagnosis was made evident by the development of a cyst large enough to be palpated.
Tearing injuries of the small bowel are most likely to occur near the points of fixation of the bowel such as near the ligament of Treitz, near the ileocecal valve, or at the root of the mesentery. Also the small bowel tends to rupture more easily on its antimesenteric border, this site presumably being weaker than the mesenteric side. Hollow viscera appear to be more readily ruptured by a blow with a ~harp object, while the solid viscera are more readily injured by a blow with a broad, crushing object. In spite of the protected position of the liver and spleen under the costal cage, they are not infrequently injured. In these cases, however, there are often associated fractures of the lower ribs or evidence of trauma over these ribs which should serve to direct attention to the underlying viscera. Fracture of the pelvis and particularly the pubic rami should direct attention to the urinary bladder and urethra.
Nonpenetrating Injuries of Abdomen
1181
All intra-abdominal hollow viscera are not completely intraperitoneal and this may cause some confusion in diagnosis if not properly considered. The most notable of the extraperitoneal hollow viscera are the duodenum, ascending colon, descending colon and bladder. Rupture of these viscera in their retroperitoneal portions does not produce the classical signs of peritoneal irritation, and they may therefore go unrecognized. The diagnosis of serious damage to intra-abdominal structures is not usually possible immediately after the accident. In this stage the severity of the pain is often less than the severity of the abdominal lesion. The same is often true of tenderness to palpation. In these cases a short period of vigilant observation may be of value. We stress the importance of keeping this period of observation short. The mortality in these cases bears a direct relationship to the length of time operative intervention is delayed. A severe blow to the abdomen usually causes a great deal of disturbance immediately and soreness in the abdomen is likely to persist for some time even when no serious intra-abdominal injury is present. Conversely, the fact that the patient appears to recover quickly from a severe blow to the abdomen does not rule out a serious intra-abdominal injury, since quite often the patient will appear to recover from the immediate effects of trauma to the abdomen, but will develop signs of visceral injury later. This has been justly labeled the "period of illusion,"3 and makes close observation imperative. The following is an illustrative case report. CASE II. L. G., aged 45, a maintenance man, was engaged in sawing a piece of wood which caught in the blade and was thrown against his abdominal wall. At first he did not think he was hurt, but soon he became nauseated and noticed severe pain about the genitals and rectum with pain later in the abdomen. He was admitted to the hospital 5 hours after the accident. Physical examination showed no surface evidence of trauma, but the abdominal wall was rigid. Operation 7% hours after the accident showed a tear of the ileum.
Comment. If such a patient is seen soon after the injury he should be kept under observation or advised to report immedia~ely after the first evidence of abdominal pain or nausea, weakness or shortness of breath on exertion. It is not unusual for a ruptured hollow viscus to result in delayed signs and symptoms several hours after the accident. Those from ruptured solid viscera may be delayed for days or weeks. EARLY TREATMENT OF SHOCK
The urgent need for the early and vigorous treatment of shock should not need to be emphasized. If shock is present when the patient is first seen, therapy should be started immediately, since it will not interfere
1182
Grover C. Penberthy, Charles R. Reiners
with other diagnostic procedures, a'1d can, in fact, be carried out simultaneously with them. An infusion of glucose in saline should be started at once. Blood transfusion should be performed as soon as possible, and as frequently as necessary. While blood is being obtained hemoglobin, hematocrit and white blood cell determinations can be made. Some index of the state of the patient can be gained from these initial determinations. They are also essential as a baseline for comparison with future determinations. A word of caution is necessary concerning the use of morphine or other narcotics before the diagnosis is established. Although morphine is acknowledged to be an excellent drug in the treatment of shock, it may hopelessly confound the diagnostic picture by masking the early signs of peritoneal irritation, pain, tenderness, and so on. Valuable time is lost thereby, and a successful outcome is further jeopardized. It is our practice to withhold morphine until such time as the decision for or against operation is established. The surgeon must use his discretion in this matter. The practice of avoiding narcotics in cases of actual or suspected cerebral injury should be stressed. In cases of early profound shock without evidence of external bleeding of sufficient degree to account for the shock, intraperitoneal bleeding must be presumed. 1£ the abdominal signs and symptoms agree with this presumption, the decision to operate must not be delayed. Ample supplies of compatible whole blood should be on hand at the time of operation. In our experience 1500 or 2000 cc. should be considered the minimum amount to have readily available. A Levin tube should be placed in the stomach early when there is evidence of intra-abdominal injury. This is valuable for several reasons. The aspirated material may contain blood. This is presumptive evidence of injury to the stomach or duodenum. A Levin tube is of therapeutic value in the presence of acute gastric dilatation which is often found in these cases, particularly in children. It is also prophylactic against the development of distention if paralytic ileus occurs, since most of the distention in these cases is from swallowed air. Aspiration of the gastric contents reduces the anesthetic hazard and is a technical aid to the surgeon in cases which subsequently come to laparotomy. ROENTGENOLOGIC SIGNS OF INJURY
The x-ray is an important adjunct to diagnosis. In all instances supine and upright flat films which include the diaphragm are essential. A chest film is also quite helpful. Recognition of fractures of the ribs, pelvis or lumbar spine and transverse processes confirms the occurrence of a severe type of trauma and directs attention to the nearby structures as probable sites of injury. The early diagnosis of rupture of the diaphragm with
Nonpenetrating Injuries of Abdomen
1183
herniation of abdominal viscera into the thorax is of extreme importance, and can be made with certainty only by x-ray studies. The presence of free air under the diaphragm is diagnostic of perforation of some portion of the gastrointestinal tract, and is an absolute indication for early laparotomy. Free air in the retroperitoneal tissues is diagnostic of perforation of the gastrointestinal tract in one of the retroperitoneal areas, in the absence of subcutaneous emphysema from a chest injury. If a chest x-ray is made, this should not be a source of confusion, especially if the x-rays are made early before the subcutaneous emphysema becomes generalized. The areas where the bowel is retroperitoneal and where such rupture can occur are notably the duodenum, ascending colon and descending colon, as previously mentioned. The loss of the psoas shadows is an indication that there is free peritoneal fluid. Localized masses or shadows in any region may indicate local hematomas or fluid collections. This is of particular importance when noted in the left upper quadrant, since it sometimes is seen in rupture of the spleen. Paralytic ileus with air-fluid levels in the small bowel may result directly from the initial trauma, or it may indicate a spreading peritonitis, and should be interpreted with caution. Acute gastric dilatation as demonstrated by a very large air bubble in the left upper quadrant may produce a clinical picture very hard to differentiate from more serious forms of intra-abdominal injury. These cases show marked tenderness, and spasm in the epigastrium with considerable distention. This condition, when severe, may produce or aggravate systemic shock. Fortunately, a ready solution is at hand in the Levin tube, as mentioned earlier. Attention is called to the danger of placing too much faith in one negative laboratory or x-ray finding. Most of the above-mentioned x-ray findings are of importance only when positive. All too often their absence is misleading, as the following case will illustrate. CASE III. L. M., aged 46, a male factory worker, was admitted to the hospital 1;!1 hours after having received a blow of moderate crushing force to the abdomen when caught between a bench and a conveyor belt. Immediately after the blow he was short of breath, but had no severe pain and did not lose· consciousness. A right inguinal hernia which had been present for 5 years became tender and more prominent after the injury. The hernia was easily reducible. The patient was admitted for observation complaining only of dull drawing pain in the lower abdomen. On examination, his blood pressure was 130/90, temperature 98.2°F., pulse 74, respiration 20. There was generalized abdominal tenderness, most marked in the right lower quadrant; slight distention; diminished peristaltic sounds; no rebound tenderness, rigidity or muscle spasm. The right inguinal hernia was tender on palpation but was easily reducible. Rectal examination was negative. Blood count was 15,400 white cells with 87 per cent polymorphonuclears, 6 per cent lymphocytes and 7 per cent monocytes. Urinalysis was negative.
1184
Grover C. Penberthy, Charles R. Reiners
Chest x-ray was negative. The flat plate of the abdomen was reported as showing "No evidence of ruptured viscus. No evidence of intestinal obstruction." The patient's condition remained essentially the same during his first day in the hospital. On the second day his abdominal distention increased as did his abdominal pain. Bowel sounds diminished and it was noted that he had had no bowel movement and had not passed gas since admission. Temperature rose to 101.3°F. and he began to vomit. A Miller-Abbott tube was passed and began to drain dark brown fluid. Temperature returned to normal. On his fourth day his temperature spiked to 104°F. The Miller-Abbott tube was draining large amounts of foul-smelling, black fluid. There was no localizing abdominal tenderness. On the evening of the fourth day laparotomy was performed and an avulsion of a large segment of the small bowel mesentery was found. A resection of the gangrenous portion of the small bowel was done, with end-to-end anastomosis of the small bowel. Immediately after the procedure the patient's condition seemed satisfactory, but soon began to deteriorate. His temperature rose to 105°F. and he died soon after in peripheral vascular collapse. ~- Comment. There are several features of this case which merit special
attention. We notice again the absence of severe pain immediately after the accident, but the subsequent development of both pain and tenderness. The false sense of security that was engendered by the negative x-ray report based on the fiat plate of the abdomen was certainly contributory to the tragic outcome in this case. It is far better to rely on the clinical picture of the patient and his progress or failure to improve during a short period of observation than to credit undue importance to the results of any single negative examination or test. CASE IV. S. W., aged 39, was admitted to the hospital 4 days after he had received a beating in a fight. He came to the hospital because of progressively severe pain in the lower left chest which was aggravated by coughing or deep breathing. He also felt weak, and had had one episode of syncope. On examination his blood pressure was 90/70 and pulse 80. There was pallor of the conjunctivae, marked tenderness and crepitation over the tenth rib in the posterior axillary line, and some tenderness in the left upper quadrant, although not marked. Bowel sounds were normal. Hemoglobin was 7.7 grams. Urine was negative. X-ray of the chest revealed a fracture of the tenth rib posteriorly, but was otherwise negative. The report on a flat plate of the abdomen was, "No evidence of abnormal mass within the left upper quadrant which is usually seen with a large hemorrhage." The tentative diagnosis was retroperitoneal hematoma. Abdominal tap was performed, but no blood was obtained. The patient was transfused with 1500 cc. of blood, and pressure rose to 130/80. On the second hospital day, laparotomy was performed and the patient was found to have a large tear of the anterior surface of the spleen with approximately 2000 cc. of old blood within the peritoneal cavity. Splenectomy was performed. The patient went into shock on the operating table, but responded to rapid transfusion after the splenic pedicle had been clamped. Recovery was uneventful.
Comment. Splenic injury should always be suspected in fractures of the tenth, eleventh or twelfth ribs on the left side. If fractures in this
Nonpenetrating Injuries of Abdomen
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area are accompanied by unexplained anemia, it is presumptive evidence of rupture of the spleen. If this anemia is progressive it is an incontrovertible indication for immediate laparotomy. Notice that in this case the absence of a mass in the left upper quadrant on x-ray examination was temporarily misleading, as was the failure to recover blood on attempted diagnostic paracentesis. After a seemingly satisfactory initial response to conservative therapy this patient had a second hemorrhage two days later which could well have been fatal. These belated hemorrhages have been known to occur after an asymptomatic interlude as long as four to six weeks from the initial injury. This patient failed to demonstrate the radiation of pain to the left shoulder which is so often a helpful diagnostic aid. Fractures of the pelvis and pubic rami are a mandate for investigation of the urinary bladder and urethra. A catheter should be passed if the patient is unable to void. If the urine contains no evidence of blood it is presumptive evidence that the bladder is intact. If, in addition, a measured amount (200 to 250 cc.) of sterile saline can be injected into the bladder and then completely recovered, the bladder may be considered intact. If, however, there is blood in the urine or saline escapes from the bladder, it is best to do cystography. An x-ray film of the lower abdomen and pelvis is made after having filled the bladder with 20 cc. of Diodrast diluted with 200 cc. of sterile saline. Injection of 200 cc. of air may accomplish the same purpose. The site of extravasation can usually be localized, which will aid materially in its discovery at operation. SUMMARY
1. It is important to take a complete history of the alleged accident and to make a physical examination, including x-rays as indicated. 2. Early and vigorous treatment of shock which is important can be continued while the diagnostic work-up is being done. 3. The use of morphine in cases of suspected intra-abdominal injury is contraindicated until the diagnosis has been definitely established. There may be an exception, depending upon the circumstances and the judgment of the physician. 4. Frequent observation with frequent re-examination is essential if the diagnosis of intra-abdominal injury is to be made early. Early operation is vital because of the direct relationship between mortality rate and the time interval between injury and operation. 5. The patient known to have suffered severe trauma to the abdomen and under observation with persistent abdominal pain, spasm and tenderness with or without nausea or vomiting should be suspected of having
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Grover C. Penberthy, Charles R. Reiners
a perforation of an abdominal viscus. If the signs persist for six hours, an exploratory laparotomy is indicated. 6. We wish finally to emphasize the necessity for early surgical exploration of the injured abdomen before every evidence that warrants this act is at hand, because irreversible complications may appear with unheralded speed. These can best be dealt with before their occurrence, not after they hold the center of the stage. REFERENCES 1. Penberthy, G. C. and Benson, C. D.: Injuries to the Abdomen in Industry. Am. J. Surg. 74,' 346, 1947. 2. Penberthy, G. C.: Acute Abdominal Injuries. Surg., Gynec. & Obst. 94: 626 1952. 3. Cogley, J. P.: The Traumatic Abdomen. J. Iowa State M. Soc., Nov., 1951 p. 451.