Hollow visceral injury refers to blunt force injury specific to the gastrointestinal system extending from the gastro-esophageal junction, stomach, small and large intestine including the rectum. Blunt forces can cause rupture of hollow viscera due to rapid compression of a segment of intestine containing fluid and air. Deceleration forces cause linear shearing and stretching between relatively free and fixed objects [1]. 

As bowel loop travel from their mesenteric attachments, tear and vascular injury of mesentery can occur. Greater the number of solid organs injured, greater are chances of small bowel and mesenteric injury. Bowel and mesentery are involved in 1/3rd cases of pancreatic and solid organ injury [1]. 

Small bowel is the most common injured organ among hollow viscus [4]. About 25% of patients requiring surgical management for bowel trauma have more than one bowel injury and likely more than one mechanism [2]. Hollow visceral injuries are far less common in blunt abdominal trauma than in penetrating abdominal trauma [3].

Hollow visceral injuries after blunt trauma remain the third most common injury in blunt abdominal trauma [4] and had a reported incidence of 1-2% of all blunt trauma cases [5]. Some studies have reported the incidence of small bowel injury to be 10% whereas large bowel injury was identified in 6% of BTA patients6. In other studies, overall incidence of hollow visceral injuries has been reported to be 21% in BTA patients requiring laparotomies7.In contrast, a large multi-center study has reported relatively lower incidence of hollow visceral injury (small bowel: 3% and colon injuries: 0.9%) from the United States [2]. 

American Association for the Surgery of Trauma (AAST) grading may be used to classify hollow visceral injury severity, but it has not been a proven predictor of mortality [8]. Most authors consider grade III injuries (50% to 75% circumferential laceration) or greater to be severe, although there remains no clear consensus on the best operative treatment of these injuries. There is some consensus on fact that surgery should be performed within 8 hours of injury in patients withx reported mortality of 15.2%11 There is contrasting reports of incidence and pattern of hollow visceral injury after BTA. No study has been there from our institute regarding the prevailing pattern of hollow visceral injury. So, we conduct this study to determine the Pattern of hollow visceral injury Injury among Blunt Trauma Abdomen patients in a tertiary care Hospital.

Aims and Objective

To determine the trend of hollow visceral Injury among Blunt Trauma Abdomen patients in a tertiary care Hospital.

Study design

Observational prospective study.

Study period

 July 2018 to December2019.

Study population

FAST-positive patients admitted in study period at ATC PGIMER Chandigarh, India were included in the study as per the inclusion and exclusion criteria. Informed understood written consent was taken from all the patients and approval from the institute’s ethical committee was obtained.

Sample size

Seventy five consecutive patients were recruited based on satisfying the inclusion and exclusion criteria. All the recruited patient's injuries were classified according to existing classification of organ injury. Pattern, prevalence, non-operative versus operative management and outcome in term of mortality and morbidity were monitored.

Eligibility

All consecutive patients with blunt trauma abdomen admitted during the time Frame of the study.

Inclusion Criteria

• All patients with blunt trauma abdomen having FAST POSITIVE or evidence of solid or

• viscous injury clinically or radio logically.

• Both Sex

• Age >14 years and <80 years

• Patients giving a valid informed consent.

Exclusion Criteria

Age <14 years as they are managed by department of pediatric surgery at PGIMER Chandigarh

• Patients who refuse to give consent.

• Patients having GCS score less than or equal to 4 on arrival.

Material & Methods

Advance Trauma Center PGIMER Chandigarh is the majortrauma center of India and it caters major population of Punjab, Haryana, Chandigarh, Himachal, Uttar Pradesh, and Bihar, J&K, Rajasthan and act as referral center for the urban and rural hospitals within the region. It has a computerized registry into which trained data collectors have prospectively entered data on all injury admissions. Patients admitted for Blunt Trauma Abdomen were taken into study and categorized into:

• Patients with hollow viscous perforation

• Patients with solid organ injury

• Patients with solid and hollow viscous organ injury along with other coexisting injuries

Patients were managed as per existing protocol of trauma guidelines of the institute and ATLS guidelines and outcome in term of morbidity mortality and length of hospital stay was monitored. Operative, non-operative management and its indications and outcomes were evaluated. 

Clinical course

Patients with blunt trauma abdomen were taken and their history was taken. Name, age, sex, residence, mode of injury, time of injury, time of arrival at ATC, brief history about antecedent incident was taken. Primary survey was done and GCS of patient and vitals such as pulse, blood pressure, respiration was noted. Airway, breathing, circulation was secured as per ATLS guidelines. Secondary survey was done, and detailed injuries were noted from head to toe.

After initial resuscitation patient underwent routine blood investigations such ABG, haemogram, blood biochemistry including electrolytes, renal function test and liver function test. Medico legal x-rays of skull with cervical spine, bilateral hip with pelvis, chest and abdominal X-ray was performed in addition injury specific x rays. FAST was done preliminary for BTA. In FAST positive patients CECT abdomen was performed and details of organ injured was noted. All the injuries noted clinically and by radiology were given an AIS and ISS score. Specific organ injuries were graded according to AAST grading of organ injuries.

Conservative or surgical management was done as per existing guidelines of institute. Conservative management includes BTA charting (hourly monitoring of pulse, blood pressure, respiration rate, urine output, abdominal girth, febrile status, 6hourly hemogram) transfusion of blood products, radiological interventions like percutaneous drainage or angioembolization, as guided by the clinical status of the patient, biochemical and radiological findings.

Surgical management for hollow viscus perforation and hemodynamically unstable solid organ injury includes exploratory laprotomy. Postoperatively, patient was monitored and managed according to clinical features, hemodynamic status with the help of biochemical and radiological investigations as indicated. Mortality and morbidity were noted

Statistical Analysis

Data were summarized and expressed as frequency and percentages. All calculations were conducted with standard statistical programs (SPSS 8.01, SPSS, Inc, Chicago IL).

Seventy-five patients admitted to Trauma center during study period were selected for the study based on inclusion and  exclusion  criteria. Following    observations were made based on their admission and their stay and management There were 75 patients who were included in this study belonged to the age group 16-75 years. The most common age group affected was 16-30 years which constitute 56% of total affected population. 61-75 years group constituted least affected group (Table 1). 

Table 1: Age and gender distribution in blunt trauma abdomen patients

Table 2: Hollow visceral injury in blunt trauma abdomen patients

Figure 1: Age & gender distribution in blunt trauma abdomen patients

Figure 2: Hollow visceral injury in blunt trauma abdomen patients

Table 3: Pattern of hollow visceral injury in blunt trauma abdomen patients

Table 4: Grade of hollow visceral injury

Figure 3: Pattern of hollow visceral injury in blunt trauma abdomen patients

Figure 4: Grade of hollow visceral injury

Table 5: Perforations in of hollow visceral injury

In the present study, hollow visceral injured in 19(25.33%) of cases, out of total 75 cases (Table 2) (Figure 2). Jejunum was found to be most common hollow visceral organ injured in this study involved in 9.3% of total blunt trauma abdomen cases followed by Duodenum in 4(5.33%) cases. Second part of duodenum was involved in 75% of duodenal injuries. Ileum was injured in 3(4.0%), colon in 4(5.33%) and rectum in 1(1.33%) of cases. Ileum was injured in 3(4.0%), colon in 4(5.33%) and rectum in 1(1.33%) of cases. (Table 3) (Figure 3) Among Jejunal injuries, Grade II (5.3%) injuries found to be more common followed by grade V (2.7%). Among duodenal injuries Four percent of total blunt trauma injuries were grade IV and grade III in 1.3%. Grade II Ileal injuries were found in 2.7% cases and grade V in 1.3% of cases. No grade I, III and gradeIV injury reported in illeal injuries. Grade I colonic injuries were found to be more common in 4% of cases and grade II injuries in 1.3% of cases (Table 4) (Figure 4). Single hollow organ perforation was found in 13.33% of cases of blunt trauma abdomen whereas more than one perforation was found in 5.33% of cases (Table 5).

Blunt abdominal trauma preferentially involves the small bowel and may result in bleeding and/or peritonitis12. Hollow viscus injury (HVI) following blunt abdominal trauma is an infrequent diagnosis. The incidence of hollow viscus injuries following blunt abdominal trauma varies from 4 to 15%. Patients with penetrating abdominal trauma have mostly HVI; however this diagnosis is infrequent in blunt abdominal trauma because the trauma should be very severe. It is well known that delay in diagnosis and treatment of the hollow viscus injury results in early peritonitis, hemodynamic instability and increased mortality and morbidity .The decrease in the rate of penetrating abdominal trauma and the increase in the rate of blunt abdominal trauma have resulted in increased rate of hollow viscus injury. Thus the early diagnosis and treatment remains the most important part of the management10. 

In the present study, hollow visceral injured in 19(25.33%) of cases, out of total 75 cases Similarly study done by Nance et al. [13] over 3089 patients of BTA 296 had hollow viscus injury (9.6%).  In contrast to our study, Hollow viscera were involved in 12.73% cases in the study done by George et al. [14].

In the current study, Jejunum was found to be most common hollow visceral organ injured in this study involved in 9.3% of total blunt trauma abdomen cases followed by Duodenum in 4(5.33%) cases. Second part of duodenum was involved in 75% of duodenal injuries. Ileum was injured in 3(4.0%), colon in 4(5.33%) and rectum in 1(1.33%) of cases. Ileum was injured in 3(4.0%), colon in 4(5.33%) and rectum in 1(1.33%) of cases. Our study results were similar to study done by Costa et al [6].

In the current study, Jejunum was found to be most common hollow visceral organ injured in this study followed by   Duodenum. Although   early  recognition 

of intestinal  or   hollow   visceral  injuries   from   blunt abdominal trauma may be difficult in all cases, it is very important due to its tremendous life-threatening potential.

1. Ameh, E.A, et al. "Gastrointestinal Injuries from Blunt Abdominal Trauma in Children." East African Medical Journal, vol. 81, 2004, pp. 194–197.

2. Watts, D.D,  et al. "Incidence of Hollow Viscus Injury in Blunt Trauma: An Analysis from 275,557 Trauma Admissions from the East Multi-Institutional Trial." Journal of Trauma, vol. 54, 2003, pp. 289–294.

3. Talton, D.S, et al. "Major Gastroenteric Injuries from Blunt Trauma." The American Surgeon, vol. 61, no. 1, 1995, pp. 69–73.

4. Wisner, D.H, et al. "Blunt Intestinal Injury: Keys to Diagnosis and Management." Archives of Surgery, vol. 125, no. 10, 1990, pp. 1319–1323.

5. Al-Hassani, A, et al. "Dilemma of Blunt Bowel Injury: What Are the Factors Affecting Early Diagnosis and Out comes." The American Surgeon, vol. 79, no. 9, 2013, pp. 922–927.

6. Costa, G, et al. "The Epidemiology and Clinical Evaluation of Abdominal Trauma: An Analysis of a Multidisciplinary Trauma Registry." Annali Italiani di Chirurgia, vol. 81, no. 2, 2010, pp. 95–102.

7. Hildebrand, F, et al. "Blunt Abdominal Trauma Requiring Laparotomy: An Analysis of 342 Polytraumatized Patients." European Journal of Trauma, vol. 32, no. 5, 2006, pp. 430–438.

8. Moore, E, et al. "Organ Injury Scaling, II: Pancreas, Duodenum, Small Bowel, Colon, and Rectum." The Journal of Trauma, vol. 30, no. 11, 1990, pp. 1427–1429.

9. Fakhry, S.M, 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." Journal of Trauma and Acute Care Surgery, vol. 48, no. 3, 2000, pp. 408–415.

10.  Jha, N.K, et al. "Characteristics of Hollow Viscus Injury    Following Blunt Abdominal Trauma: A Single Centre Experience from Eastern India." Bulletin of Emergency & Trauma, vol. 2, no. 4, 2014, pp. 156.