The anatomy and physiology of the abdomen is incredibly interesting. The upper right contains the gallbladder, the duodenum of the intestines, the majority of the liver, and a small portion of the pancreas. The upper left contains the spleen, most of the stomach, and the larger portion of the pancreas. The left lower contains the colon and portions of the small and large intestines. The right lower contains the appendix as well as a large portion of the small intestines. Remember, right and left are from the patient’s point of view.
Hollow organs include the stomach, large and small intestines, gallbladder, ureters, urinary bladder, appendix, rectum, and fallopian tubes. Mainly, food in various stages of digestion passes through these. When ruptured or lacerated, these organs may spill their contents into the abdominal cavity, resulting in inflammation and possible infection—stomach acid could leak into the lining of the cavity called the peritoneum. As a result, there is a condition called peritonitis: severe pain, tenderness, and muscular spasm. The small intestine is comprised of the duodenum, jejunum, and ileum. The large intestine is composed of the cecum, colon, and rectum. Blood comes from the mesentery, which is any fold of tissue that attaches an organ to the body wall. The intestinal mesentery is a fold of tissue that contains a web of vessels, both arteries and veins, as well as nerves and lymphatic tissues. Both blunt and penetrating abdominal injuries can affect this vasculature, and the patient can bleed significantly into the peritoneal cavity.
Solid organs include the liver, spleen, pancreas, kidneys, and adrenal glands. These carry out numerous chemical processes in the body, including enzyme production, blood cleansing, endocrine functions, and energy production. Their injury can result in severe, unseen hemorrhage. Blood that has escaped from solid organs can cause peritoneal irritation, but not always. Many of the solid organs are considered retroperitoneal because they are situated primarily in the posterior aspect of the abdominal cavity and behind the peritoneum. The abdominal aorta and a portion of the inferior vena cava, as well as the kidneys, ureters, urinary bladder, and colon, are also included.
These are some examples of open and closed injuries to the abdominal area. Seatbelt trauma from having your seatbelt positioned too high or too low can cause injury. If positioned too high, as is often the case in pregnant patients, it can make the uterus more vulnerable. In addition to entrance and exit wounds, medium- and high-velocity projectiles create a temporary wound channel called cavitation, which happens when the pressure wave from the projectile is transferred to the tissue. You must consider that any patient with penetrating trauma below the xiphoid process may have punctured the diaphragm. The resulting opening could create a passageway through which abdominal contents might pass, or herniate, into the thoracic cavity, potentially hindering chest expansion and causing respiratory complications. When organs protrude from the peritoneum, it is called an evisceration.
Hollow and solid organs of the abdomen can be injured in different ways. These symptoms can take a few hours to days to develop. Both penetrating and blunt trauma can cause injuries to the hollow organs. Blunt trauma causes the organ to “pop,” thus releasing fluids or air. Air in the peritoneal cavity is abnormal and usually indicates that a hollow organ or loop of bowel has perforated. If not identified and repaired, severe infection and septic shock may develop. Solid organs can bleed significantly and cause rapid blood loss that can be hard to identify from a physical examination because the patient is not experiencing significant pain. A common finding in a patient with an injured liver is referred pain to the right shoulder. Referred left shoulder pain also occurs in some cases of splenic injury. If the diaphragm is penetrated or ruptured, loops of bowel may herniate into the thoracic cavity. The patient may experience dyspnea, and changes in position from upright to supine may result in more abdominal contents spilling into the thoracic cavity and compressing the lungs, preventing full expansion. If a kidney is injured, a common finding is hematuria, or blood in the urine. Melena (black, tarry stools) and coffee-ground emesis could be the result of partially digested blood. When a patient complains of tearing pain that travels from the abdomen to the back, he or she could be experiencing a dissecting abdominal aneurysm. Pain that radiates from the lateral hip to the midline of the groin might be a sign of damage to the kidneys or ureter. Pain in the right lower quadrant may indicate an inflamed or ruptured appendix. When the gallbladder is injured or inflamed, the pain may be just under the margin of the ribs on the right side or between the shoulder blades. Watch for rebound tenderness. The patient may be guarding, where they tense up abdominal muscles in an effort to splint the area. The patient may prefer to lie still with the knees drawn to the chest.
When a person has experienced an open abdominal injury, stabilize the object and bandage in cases of penetrating injury with an impaled object. For eviscerations, make sure to place a sterile dressing moistened with normal saline over the wound, apply a bandage, and transport. Avoid using adherent material and those that lose substance when wet.
For traumatic injuries sustained by males and females to the genitourinary system, there are a number of signs. Suspect kidney damage if there is any abrasion, laceration, or contusion in the flank, a penetrating wound in the flank, fractures on either side of the lower rib cage or of the lower thoracic or upper lumbar vertebrae, or a hematoma in the flank region. Injuries to the bladder may cause urine to spill into the surrounding tissues, and any urine that passes through the urethra is likely to contain blood. In the second and third trimesters, injury to the urinary bladder is increased by displacement of the uterus. Injuries of the external male genitalia include all types of soft-tissue wounds and are not typically life-threatening. In the third trimester of pregnancy, the uterus is large and may obstruct the vena cava if the patient is placed in a supine position (supine hypotensive syndrome). The patient should lie carefully on the left side so that the uterus will not lie on the vena cava. In cases of external bleeding and trauma, a sterile absorbent sanitary napkin or pad may be applied to the labia. Do not insert instruments or tampons into the vagina.
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