Blunt abdominal trauma is the most common cause of solid organ injuries like liver, spleen, kidney etc. The most common cause of blunt abdominal trauma is road traffic accident followed by fall from height. Other causes include assault, bull gore injury, natural calamities, sports injuries, bomb blasts etc.^1,2 Blunt abdominal trauma is usually missed during clinical examination mainly in case of early presentations, which makes clinical diagnosis and early management of blunt abdominal traumas difficult which may increase fatality of such patients.

However there is increased mortality and morbidity of patients of blunt abdominal trauma due to increased interval between trauma and hospitalization, inadequate and lack of appropriate surgical treatment, delay in diagnosis, post operative complications and associated trauma especially to head, thorax.^3,4

Present day modern diagnostic techniques have increased the early and accurate identification of blunt abdominal trauma with solid organ injuries which enable us to provide appropriate treatment for such patients.⁵ Now a days non-operative management [NOM] for blunt abdominal trauma with solid organ injuries is gaining importance over surgical intervention due to adequate monitoring and advanced imaging techniques. Present study was aimed to study outcomes of non-operative management of blunt abdominal trauma with solid organ injuries.a

Present study was single-center, prospective, observational study, conducted in department of General Surgery, Karnataka Institute of Medical Sciences, Hubballi, India. Study duration was of 2 years (January 2021 to January 2023). Study was approved by institutional ethical committee.

Inclusion criteria

• All cases with history of blunt trauma to abdomen due to various causes like road traffic accident, fall from height, assault to the abdomen with a blunt object, natural calamity, having a clinical suspicion of trauma to the abdomen, willing to participate in present study.

Exclusion criteria

• Patient with penetrating abdominal injury (e.g.: stabbing & gunshot injuries).

Study was explained to participants in local language & written informed consent was taken. On admission, after necessary resuscitative measures, all the patients were evaluated with a detail history and a thorough clinical examination followed the by the necessary laboratory investigations and radiological assessment [FAST /CT scan]. After initial resuscitation of the patients, thorough assessments for injuries were carried out in all the patients. Details of patients like name, age, sex, occupation and nature and time of accident leading to the injury, history, clinical findings, laboratory investigations, radiological assessment, continuous serial monitoring of patient were done and complications during the stay in the hospital were all recorded on a Proforma specially prepared. Based on the history, clinical examination, hemodynamical stability, laboratory investigations, Diagnostic peritoneal lavage (DPL) and radiological assessment including Focussed assessment with sonography in trauma (FAST) and Computed tomography (CT) abdomen and pelvis, the decision for operative or nonoperative management (N.O.M) were taken. And patients selected for N.O.M were considered for the study.

Patients selected for N.O.M were shifted to SICU and placed on strict bed rest, nil per oral with adequate analgesics and antibiotics and were subjected to serial clinical examination which included hourly pulse rate, blood pressure, respiratory rate and repeated examination of abdomen and other systems. And repeated assessment of hemoglobin levels and abdominal girth, urine output monitoring were done. Appropriate diagnostic tests especially ultrasound of abdomen was repeated as and when required. If the patients were converted from N.O.M to operative management due to hemodynamical instability and the operative findings were noted.

Cases are followed up till their discharge from the hospital. The above facts are recorded in a proforma prepared for this study. N.O.M is successful if the patient with blunt trauma abdomen with solid organ injury is managed without any surgical intervention and discharged from hospital. Failure of N.O.M is defined as laparotomy performed more than 12 hours after admission, after the patient was initially considered for N.O.M. Patients were admitted and managed and total number of cases who continued with N.O.M and who were converted into operative management were studied.

Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Statistical analysis was done using descriptive statistics.

Among 63 cases, majority were from 21-30 years age group (38.1 %) followed by 31-40 years age group (22.2 %). Minimum age was 15yrs and Maximum age was 75yrs with Mean age 32.41+ 12.67 yrs. Among the study subjects 92% were males and 8% were females. Road traffic accidents (RTA) was common mode of injury (61.9 %).

Table 1: General characteristics

On examination, common findings were tenderness (93.7 %), guarding (38.1 %), distension of abdomen (9.5 %), hypotension (12.7 %), tachycardia (47.6 %) & positive diagnostic peritoneal lavage (DPL) (61.9 %).

Table 2: Clinical features

Common associated injuries with blunt abdominal injury were thoracic injury (30.16 %), orthopedic injury (14.3 %), thoracic injury + orthopedic injury (11.4 %) & head injury (3.17 %).

Table 3: Associated other injuries with blunt abdominal injury

On admission, majority patients had hemoglobin levels > 12 gm % (38.1 %) followed by 11-12 gm % (17.5 %) & 9-10 gm % (15.9 %). Blood transfusion was required in 30 patients.

Table 4: Distribution of subjects according Hemoglobin

In present study, commonly injured organs were liver (53.96 %), spleen (26.98 %) & kidney (9.52 %).

Table 5: Frequency Distribution of organ injured

In present study, we noted that severity of organ injured was Grade 2 (46.03 %) & Grade 3 (36.5 %).

Table 6: Frequency Distribution of severity of organ injured

According to AAST grading, among liver injury majority had Grade 2 (46.2 %) & Grade 3 (33.3 %) injuries. Among renal injury majority had Grade 2 (40 %) & Grade 3 (30 %) injuries.

Among splenic injury majority had Grade 2 (42.1 %) & Grade 3 (36.8 %) injuries.

Table 7: Injuries according to AAST grading

Successful conservative management was observed in 61 patients (96.83). Conversation rate was 3.17% in our study.

Table 8: Distribution of subjects according to Outcome

The participants in this study were chosen from the Karnataka institute of medical science, Hubballi, who were admitted in various surgical and allied departments. Among the study population of 63 participants, 92% males and 8% females. According to the Davis et al.,⁶ males are more likely to be victims of blunt trauma abdomen. According to a study by Bansod AN et al.,⁷ out of 48 patients 42 (87.5%) cases were male and 6 (12.5%) were female. Males are slightly more likely than females to be involved in RTAs, bull gore injuries and assaults. Males are mostly the one who drink and drive.

According to a study by Bansod AN et al.,⁷ maximum cases were of age group 21-30 years (41.66%) and 31-40 years (31.25%). Similar findings were noted in present study.

According to the study at initial presentation 8 patients presented with hypotension that is systolic blood pressure 90mmHg or less that accounted for 12.7% of study participants.

According to the study at initial presentation 33 patients were found to have normal pulse rate and 30 patients were found to have tachycardia which accounted for 52% and 48% respectively. According to the study, 6 (9.5%) out of 63 patients presented with abdominal distension, 59 (93.7%) out of 63 patients presented with tenderness in respective quadrants and 24 (38.1%) out of 63 patients presented with guarding of respective quadrants. Which made abdominal pain as the most common symptom and tenderness in any quadrant of abdomen to be the most common sign. Few cases of blunt trauma were asymptomatic on presentation.

According to a study by Bansod AN et al.,⁷ 28 (66.67%) cases had abdominal pain as the commonest symptom while tenderness in 38 (79.17%) cases. According to the study 39 (61.9%) patients showed hemorrhagic peritoneal aspirate on diagnostic peritoneal lavage and 24 (38.1%) patients showed negative results in DPL. Study showed that negative DPL does not rule out hemoperitoneum. Similar findings were noted in present study.

In the study subjects 19 (30.16%) patients had associated thoracic injuries which included multiple rib fractures, pneumothorax and hemothorax. Which were managed with intercostal drainage tube insertion and nebulization and chest physiotherapy. And 9 (14.3%) patients had associated long bone fractured and pelvic bone fractures which were managed by immobilisation of the limb and pelvic binders respectively. And 2 (3.17%) patients had associated head injury which included brain parenchymal contusions which were managed by antiepileptic medications and antioedema medications. 7 (11.4%) patients had associated head injury with thoracic injury which were managed similarly.

In this study 34 (53.96%) patients had liver injuries followed by 17 (26.98%) patients had splenic injuries, 6 (9.52%) patients had renal injury, 4 (6.34%) patients had both liver and splenic injury, 1 (1.58%) patient had liver and renal injury and 1 (1.58%) patient had both splenic and renal injury. According to this study liver is the most common organ injured in blunt abdominal trauma. But according to the literature spleen is the most common organ injured in blunt trauma abdomen.^8,9,10 But in our study liver was found to be most common organ injured.

In this study, out of 63 patients managed non-operatively, success rate was found to be 96.82% that is 61 patients did not require any surgical intervention and were discharged making non-operative management to be 96.82%. Whereas failure rate was found to be 3.17% that is 2 patients had to be converted into exploratory laparotomy, so the non-operative management failure incidence was 3.17%, which is comparable with the following studies.

In the study by Hsieh et al.,¹¹ of which 80 (88 percent) were managed nonoperatively with a failure rate of 3.7% (3/80). According to a study by Bansod AN et al.,⁷ out of 48 patients, conservative management was successful in 40 (83.33%) cases and failed in 8 (16.67%) cases. Mortality of the study was 1(2.08%) case.

According to a 10 year review by Raza M et al.,⁸ out of 1071 patients initially selected 963 (89.91%) were managed non-operatively, the remaining 108 (10.08%) were subjected to laparotomy due to failure of non-operative management. According to a study by Fodor M et al.,⁹ non-operative management was successful in 584 patients (96.7% of NOM cases). Twenty failures (3.3%) were observed, and this rate was consistent over 17 years (p =0.515). Underlying causes for non-operative management failure did change over time with the most relevant cause being hemodynamic instability due to persistent or secondary bleeding lately (90% compared to previously 45.5%); however, this was not statistically significant (p = 0.123).^12,13

In this study the most common cause of blunt trauma abdomen was road traffic accidents, common among males. The liver was the most affected organ due to blunt abdominal trauma followed by spleen. Most of the patients with blunt abdominal trauma with solid organ injuries were associated with thoracic injury who needed immediate intercostal drainage. Nonoperative management had safe outcomes and high success rates with minimal conversion rates.

Hypotension, tachycardia, low Hb at presentation, positive DPL were not the indications of immediate surgical intervention. Multi organ injury and associated injuries did not change the success rates of nonoperative management. Success rates in this study with nonoperative management was found to be 96.32% with minimal failure rates of 3.17%. Hence nonoperative management should be preferred over operative management in case of blunt abdominal trauma with solid organ injuries.

Conflict of Interest: None to declare

Source of funding: Nil

1. Cusheri A, Giles G. R., Moosa A. R: Essential Surgical Practice; Butterworth International Ed. 1998: p263-304..
2. Sabiston’s Text book of surgery: 18th edition: vol 1: 2004: p483-531
3. Maingots Abdominal Operations 12^th edition chp perspective on liver surgery p970.
4. Bailey and Love 27^th edition chp the liver p1155..
5. Lee PC, Lo C, Wu JM, Lin KL, Lin HF, Ko WJ. Laparoscopy decreases the laparotomy rate in hemodynamically stable patients with blunt abdominal trauma. Surgical innovat ion. 2014 Apr;21(2):155-65.
6. Joe Jack Davis, Isidore Cohn, Francis C. Nance; Diagnosis and management of Blunt abdominal trauma. Ann, Surg, June 1976: vol 183: No 6; p672 -678.
7. Bansod, A. N., Umalkar, R., Shyamkuwar, A. T., Singade, A., Tayade, P., & Awachar, N. (2018). A study of role of non-operative management in blunt abdominal trauma with solid organ injury. International Surgery Journal, 5(9), 3043–3050.
8. Raza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. Non operative management of abdominal trauma - a 10 years review. World J Emerg Surg. 2013 Apr 5;8:14.
9. Fodor M, Primavesi F, Morell-Hofert D, Kranebitter V, Palaver A, Braunwarth E, Haselbacher M, Nitsche U, Schmid S, Blauth M, Gassner E, Öfner D, Stättner S. Non-operative management of blunt hepatic and splenic injury: a time-trend and outcome analysis over a period of 17 years. World J Emerg Surg. 2019 Jun 17;14:29.
10. Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma. 2005; 58: 492-498.
11. Hsieh TM, Cheng Tsai T, Liang JL, Che Lin C. Non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy. World J Emerg Surg. 2014 Sep 25;9(1):51.
12. Dent D, Alsabrook G, Erickson BA, Myers J, Wholey M, Stewart R,Root H, Ferral H, Postoak D, Napier D, Pruitt BA Jr. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization. J Trauma. 2004; 56: 1063-1067.
13. Killeen KL, Shanmuganathan K, Boyd-Kranis R, Scalea TM, Mirvis SE. CT findings after embolization for blunt splenic trauma. J Vasc Interv Radiol. 2001;12: 209-214.