Hollow viscus blunt abdominal trauma in children
- Haley Guzzo, MD
Haley Guzzo, MD
- Johns Hopkins Department of Anesthesiology and Critical Care Medicine
- William Middlesworth, MD, FAAP, FACS
William Middlesworth, MD, FAAP, FACS
- Assistant Professor of Surgery and Pediatrics
- Columbia University College of Physicians & Surgeons
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Hollow viscus injuries in children resulting from blunt abdominal trauma are usually inflicted by forceful mechanisms that cause serious associated injuries. The diagnosis of hollow viscus injury may be delayed, since the more obvious solid visceral injuries that frequently accompany them are managed nonoperatively, and imaging studies (specifically computed tomographic [CT] scan), when performed soon after the injury, may fail to demonstrate them. Definitive management of children with blunt abdominal trauma who are evaluated for hollow viscus injury depends on clinical findings. Most require surgical intervention.
This topic will review blunt hollow visceral injuries in children, including mesenteric injury, duodenal hematoma, and perforation of the stomach, small intestine, and colon. Evaluation and management of traumatic liver, pancreas, and splenic injuries in children are discussed separately. (See "Liver, spleen, and pancreas injury in children with blunt abdominal trauma".)
In addition, bowel injuries associated with rectal foreign bodies are reviewed elsewhere. (See "Rectal foreign bodies", section on 'Complications'.)
Blunt abdominal trauma occurs frequently in childhood but seldom results in significant hollow visceral injury. The overall frequency of blunt hollow visceral injuries among children in the United States ranges from <1 to 5 percent in large reviews of pediatric blunt abdominal trauma [1-6]. Injury to the small bowel (specifically jejunal perforation) is seen most commonly, followed by injury to the duodenum, colon, and stomach [1-3].
The majority of gastrointestinal (GI) injuries are caused through a discrete point of energy transfer (eg, direct blow, seat belt injury, bicycle handlebar injury) . Motor vehicle accidents are the most prevalent cause in reviews from pediatric trauma centers [2,4,7-12]. Falls and bicycle handlebar injuries are other frequent causes [3,4,7-9,11].
- Allen GS, Moore FA, Cox CS Jr, et al. Hollow visceral injury and blunt trauma. J Trauma 1998; 45:69.
- Bensard DD, Beaver BL, Besner GE, Cooney DR. Small bowel injury in children after blunt abdominal trauma: is diagnostic delay important? J Trauma 1996; 41:476.
- Canty TG Sr, Canty TG Jr, Brown C. Injuries of the gastrointestinal tract from blunt trauma in children: a 12-year experience at a designated pediatric trauma center. J Trauma 1999; 46:234.
- Jerby BL, Attorri RJ, Morton D Jr. Blunt intestinal injury in children: the role of the physical examination. J Pediatr Surg 1997; 32:580.
- Ciftci AO, Tanyel FC, Salman AB, et al. Gastrointestinal tract perforation due to blunt abdominal trauma. Pediatr Surg Int 1998; 13:259.
- Gaines BA, Shultz BS, Morrison K, Ford HR. Duodenal injuries in children: beware of child abuse. J Pediatr Surg 2004; 39:600.
- Holland AJ, Cass DT, Glasson MJ, Pitkin J. Small bowel injuries in children. J Paediatr Child Health 2000; 36:265.
- Albanese CT, Meza MP, Gardner MJ, et al. Is computed tomography a useful adjunct to the clinical examination for the diagnosis of pediatric gastrointestinal perforation from blunt abdominal trauma in children? J Trauma 1996; 40:417.
- Desai KM, Dorward IG, Minkes RK, Dillon PA. Blunt duodenal injuries in children. J Trauma 2003; 54:640.
- Moss RL, Musemeche CA. Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg 1996; 31:1178.
- Ulman I, Avanoğlu A, Ozcan C, et al. Gastrointestinal perforations in children: a continuing challenge to nonoperative treatment of blunt abdominal trauma. J Trauma 1996; 41:110.
- Trokel M, DiScala C, Terrin NC, Sege RD. Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes. Child Maltreat 2004; 9:111.
- Saladino RA, Lund DP. Abdominal trauma. In: Textbook of Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig S (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.1271.
- Lutz N, Arbogast KB, Cornejo RA, et al. Suboptimal restraint affects the pattern of abdominal injuries in children involved in motor vehicle crashes. J Pediatr Surg 2003; 38:919.
- Sokolove PE, Kuppermann N, Holmes JF. Association between the "seat belt sign" and intra-abdominal injury in children with blunt torso trauma. Acad Emerg Med 2005; 12:808.
- Grosfeld JL, Rescorla FJ, West KW, Vane DW. Gastrointestinal injuries in childhood: analysis of 53 patients. J Pediatr Surg 1989; 24:580.
- Shilyansky J, Pearl RH, Kreller M, et al. Diagnosis and management of duodenal injuries in children. J Pediatr Surg 1997; 32:880.
- Nance ML, Keller MS, Stafford PW. Predicting hollow visceral injury in the pediatric blunt trauma patient with solid visceral injury. J Pediatr Surg 2000; 35:1300.
- Newman KD, Bowman LM, Eichelberger MR, et al. The lap belt complex: intestinal and lumbar spine injury in children. J Trauma 1990; 30:1133.
- Choit RL, Tredwell SJ, Leblanc JG, et al. Abdominal aortic injuries associated with chance fractures in pediatric patients. J Pediatr Surg 2006; 41:1184.
- Lutz N, Nance ML, Kallan MJ, et al. Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. J Pediatr Surg 2004; 39:972.
- Durbin DR, Arbogast KB, Moll EK. Seat belt syndrome in children: a case report and review of the literature. Pediatr Emerg Care 2001; 17:474.
- Watts DD, Fakhry SM, EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the East multi-institutional trial. J Trauma 2003; 54:289.
- Clendenon JN, Meyers RL, Nance ML, Scaife ER. Management of duodenal injuries in children. J Pediatr Surg 2004; 39:964.
- Timaran CH, Daley BJ, Enderson BL. Role of duodenography in the diagnosis of blunt duodenal injuries. J Trauma 2001; 51:648.
- Stylianos, S, Pearl, SH. Abdominal Trauma. In: Pediatric Surgery, Grosfield, JL, Fonkalsrud, EW, Coran, AG (Eds), Elsevier, Philadelphia p.295.
- Kunin JR, Korobkin M, Ellis JH, et al. Duodenal injuries caused by blunt abdominal trauma: value of CT in differentiating perforation from hematoma. AJR Am J Roentgenol 1993; 160:1221.
- Oztürk H, Onen A, Otçu S, et al. Diagnostic delay increases morbidity in children with gastrointestinal perforation from blunt abdominal trauma. Surg Today 2003; 33:178.
- Fakhry SM, Brownstein M, Watts DD, et al. Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma 2000; 48:408.
- Burch, JM. Injury to the Colon and Rectum. In: Trauma, Feliciano, DV, Moore, EE, Mattox, KL (Eds), Appleton & Lange, Stamford 1996. p.595.
- Williams MD, Watts D, Fakhry S. Colon injury after blunt abdominal trauma: results of the EAST Multi-Institutional Hollow Viscus Injury Study. J Trauma 2003; 55:906.
- Juern J, Schmeling D, Feltis B. Transanal wading pool suction-drain injury resulting in complete evisceration of the small intestine: case report and review of the literature. J Pediatr Surg 2010; 45:E1.
- Rance CH, Singh SJ, Kimble R. Blunt abdominal trauma in children. J Paediatr Child Health 2000; 36:2.
- Flood RG, Mooney DP. Rate and prediction of traumatic injuries detected by abdominal computed tomography scan in intubated children. J Trauma 2006; 61:340.
- Miller D, Garza J, Tuggle D, et al. Physical examination as a reliable tool to predict intra-abdominal injuries in brain-injured children. Am J Surg 2006; 192:738.
- Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care 2006; 22:480.
- Fakhry SM, Watts DD, Luchette FA, EAST Multi-Institutional Hollow Viscus Injury Research Group. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma 2003; 54:295.
- Harris HW, Morabito DJ, Mackersie RC, et al. Leukocytosis and free fluid are important indicators of isolated intestinal injury after blunt trauma. J Trauma 1999; 46:656.
- Gurland B, Dolgin SE, Shlasko E, Kim U. Pneumatosis intestinalis and portal vein gas after blunt abdominal trauma. J Pediatr Surg 1998; 33:1309.
- Wu JW, Chen MY, Auringer ST. Portal venous gas: an unusual finding in child abuse. J Emerg Med 2000; 18:105.
- Mueller GP, Cassady CI, Dietrich RB, et al. Pediatric case of the day. Occult child abuse (manifesting with pneumatosis intestinalis and portal venous gas). Radiographics 1994; 14:928.
- Strouse PJ, Close BJ, Marshall KW, Cywes R. CT of bowel and mesenteric trauma in children. Radiographics 1999; 19:1237.
- Kurkchubasche AG, Fendya DG, Tracy TF Jr, et al. Blunt intestinal injury in children. Diagnostic and therapeutic considerations. Arch Surg 1997; 132:652.
- Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006; 41:72.
- Peters E, LoSasso B, Foley J, et al. Blunt bowel and mesenteric injuries in children: Do nonspecific computed tomography findings reliably identify these injuries? Pediatr Crit Care Med 2006; 7:551.
- Holmes JF, Offerman SR, Chang CH, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med 2004; 43:120.
- Streck CJ, Lobe TE, Pietsch JB, Lovvorn HN 3rd. Laparoscopic repair of traumatic bowel injury in children. J Pediatr Surg 2006; 41:1864.
- Letton RW, Worrell V, APSA Committee on Trauma Blunt Intestinal Injury Study Group. Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric trauma patient. J Pediatr Surg 2010; 45:161.
- Child abuse
- Seat belt syndrome
- ANATOMIC ASPECTS OF SPECIFIC INJURIES
- Small intestine
- Pool suction entrapment and evisceration
- Initial assessment
- Physical examination
- Ancillary studies
- - Laboratory studies
- - Imaging
- - Diagnostic peritoneal lavage
- Child protection
- OPERATIVE MANAGEMENT
- Time to surgical intervention
- SUMMARY AND RECOMMENDATIONS