Around 8% of injured children will have an injury involving their abdomen and 9% of these end with a fatal result of

which 22% will be directly attributable to their abdominal injury (Cooper et al. 1994). Blunt abdominal trauma is seen
with much greater frequency than penetrating trauma, however the later is 1.4 times more likely to end in fatality
(Cooper et al. 1994). Much progress has been made in the past two decades on the imaging of children with blunt
abdominal trauma. This along with a better understanding of the pathophysiology has led to a sharp decline in the
laparotomy rate. There are many differences in the assessment and management of abdominal trauma between
adults and children, and this will remain the focus of this section.

Anatomy
Several anatomical factors combine to make the child more vulnerable than an adult to abdominal organ injury. The
child’s smaller size, thin abdominal wall, and cartilaginous ribs mean a greater force is transmitted to the abdominal
organs. The close proximity of the abdominal organs will also increase the chance of multi-organ injury. Also the more
horizontal position of the diaphragm in a child means that the liver and spleen lie lower and more anteriorly and thus
more vulnerable to injury. The thin abdominal wall also makes it prudent to assume that all penetrating injuries have
entered the peritoneal cavity till proven otherwise.

Mechanism of injury
Blunt abdominal trauma remains the commonest cause of abdominal injury to the child. In the USA blunt trauma
makes up 83% of all paediatric abdominal trauma (Cooper et al. 1994) whereas in Australia it makes up 97%. Motor
vehicle accidents are responsible for the majority of blunt abdominal injuries with slightly more occupant injuries
(41%) than pedestrian (33%). Falls make up the next highest group (8%) followed by bicycle injuries (7%) (Cooper et
al. 1994). Proper use of seat belts with the use of car chairs and booster seats would reduce the injury rate
significantly. Lap belt injuries are common in children and characteristically produce the triad of transverse abdominal
wall ecchymosis, intestinal injury, and a flexion-distraction fracture to a lumbar vertebra (Chance fracture) (Newman
et al. 1990). Handlebar injuries often cause severe organ damage due to the force being applied through a small
cross-sectional area. Commonly damaged organs from handle bar injuries include: spleen, liver, pancreas, kidney,
and intestine (specifically causing duodenal haematomas and bowel perforations) (Clarnette et al. 1997).

Penetrating injuries although less common than blunt are associated with a higher mortality rate. In the USA
penetrating injuries are usually the result of a stab or gunshot wounds whereas in Australia most penetrating injuries
are minor.
Child abuse is unfortunately very common and is the leading cause of trauma death in infants.

Abdominal injury from child abuse carries a mortality rate as high as 45% (Cooper et al. 1988). These injuries are
often the result of a punch or kick. A neglected infant who is the victim of child abuse can present moribund with
rupture of intraabdominal organs. A high index of suspicion with a careful history and detailed examination is
mandatory in any child suspected of being abused to prevent repeated assault. The presenting problem is frequently
minor e.g. a finger injury, which can distract attention from a more serious abdominal injury.

Key points
 • Anatomy and mechanism of injury lead to many differences in the assessment and management of
abdominal trauma between adults and children.

General plan of management

The management of a child with abdominal trauma should follow the basic principals of any trauma resuscitation ie:
primary survey with treatment at each stage followed by the secondary survey. Abdominal examination normally
comes into the secondary survey but may have to be included in the circulation phase of the primary survey if the
child remains hypotensive after fluid resuscitation. The child is physiologically more resilient than an adult to blood
loss. The first indication of hypovolaemia in the child is tachycardia, and hypotension may not become manifest until
45% of blood volume is lost. When intraabdominal haemorrhage from blunt trauma is suspected and the child is still
unstable after 40-60ml/Kg crystalloid resuscitation, one should give 10ml/Kg of packed red cells, and if still unstable
should be taken immediately to theatre for laparotomy (American College of Surgeons, 1997). If the child is stable or
becomes stable after resuscitation a non operative approach can be undertaken. This approach followed the
realization in the 1970’s that most abdominal organ injuries in children stop bleeding spontaneously, and with time
even the most severely damaged organs will usually heal. This approach depends on a surgeon being present and
frequently re-examining the child. The child should be able to be immediately taken to theatre if they become
unstable or develop signs of peritonitis signifying bowel perforation. Therefore the management of abdominal trauma
in children should only be performed in institutions where the child can be fully managed, including laparotomy and
after-care.

Children will frequently air swallow when involved in trauma. This can lead to gastric distension, which not only
impairs respiration but is also quite painful to palpate making abdominal assessment difficult. In these children a
gastric tube should be passed, remembering that it should be orogastric in the presence of cranial or facial injuries. A
urinary catheter is helpful in the child sustaining major trauma as urine output is a good indicator of haemodynamic
status. A catheter should only be passed after one has checked that there are no signs of urethral injury (see renal
section).

Key points

• Children are more resistant than adults to the effects of blood loss and the signs of hypovolaemia may not
be apparent until 45% of blood volume is lost.

• Non-operative management may be possible in children even in severe organ trauma. However the child
should be taken to theatre if they become unstable.

• Gastric distension due to swallowed air can present a problem to assessment

Investigations
Blood tests
Serum amylase measurement is useful as one will see a rise not only in traumatic pancreatitis but also with small
bowel injuries. Beware that parotid trauma can also give an elevated serum amylase. Liver enzymes are usually
elevated with hepatic damage (Sahdev et al. 1991, Hennes et al. 1990) and have been shown to be a useful indicator
of occult hepatic injury in victims of child abuse (Coant et al. 1992).

Urinalysis
Microscopic and macroscopic haematuria apart from being an indicator of urinary tract damage are also an indicator
of other intraabdominal organ injury especially of the spleen and liver. However this only remains true when there are
other positive abdominal signs on examination (Taylor et al. 1988).

Plain x-ray
A plain abdominal film can be useful in detecting the presence of free gas signifying a bowel perforation. However this
investigation is only positive in 25%-46% of perforations and should not be use to rule out the possibility of a visceral
injury (Ulman et al. 1996, Ciftci et al. 1998). Other helpful signs on a plain abdominal film are loss of the psoas
shadows, retroperitoneal gas (in the presence of a duodenal perforation), and bony injuries including lower rib,
vertebral, and pelvic fractures. In the case of penetrating trauma a foreign body may be located.

Ultrasound
It has been shown in the paediatric trauma setting that free intraabdominal fluid correlates very well with organ injury
(Taylor et al. 1995, Akgur et al. 1997). Ultrasound examination has been shown to be very reliable in detecting this
free fluid and is being increasingly used as a trauma room screening tool (Patrick et al. 1998, Katz et al. 1996). The
FAST (focused abdominal sonography in trauma) examination looks at pockets in the peritoneal cavity where blood
will collect in the supine position ie: retrovesical pouch or pouch of Douglas in males and females respectively,
Morrison’s pouch, spleno-renal recess and right and left paracolic gutters. The advantage of this examination is that it
can be performed in the trauma room, takes less than 3 minutes to perform, does not use ionizing radiation, and is
repeatable. The FAST examination technique is fairly easy to learn (Ingeman et al. 1996) and is increasingly being
used successfully by non-radiologists in the trauma room. Although this test is sensitive, it does not demonstrate the
injured organ, therefore a positive test in a stable child is an indication that the patient requires a CT scan. It is also
useful in the multitrauma patient in whom initial resuscitation has not been successful and one is not certain where
the bleeding source is. In this situation a FAST examination would rapidly confirm whether the bleeding was
intraabdominal or not.

CT scan
CT scanning with the use of intravenous and oral contrast has become invaluable in the assessment of abdominal
trauma (Ruess et al. 1997, Graham and Wong 1996). First reported by Rance and Bear (1980), the examination will
usually demonstrate specific organ injuries allowing for effective triage and a more focused plan of management
(Neish et al. 1998). The main drawback of this examination is that it must be performed in the radiology department
and therefore can only be done when the child is haemodynamically stable. Although CT will pick up many intestinal
injuries, some will be missed and a negative examination is no substitute for frequent clinical assessment (Bensard et
al. 1996,.Akgur et al. 1997)

Diagnostic peritoneal lavage

Diagnostic peritoneal lavage (DPL) has greatly declined in popularity in children mainly due to the realization that the
majority of solid organ injuries can be managed non-operatively. Disadvantages include that it is a painful test and will
cause distress to the conscious child, it can be the cause of intraabdominal trauma, and is non-specific when positive.
The fact that fluid and gas are put into the peritoneal cavity makes interpretation of subsequent imaging difficult. The
only area that DPL may have a role in children is in the situation where a child must be rushed to theatre for an
extraabdominal injury and one wishes to rule out a major abdominal injury. Trauma room ultrasound should make this
last indication invalid.

Laparoscopy
The role and safety of laparoscopy for the diagnosis and treatment of intra-abdominal trauma in children is
controversial and a case has yet to be proven. However some preliminary studies have yielded promising results
(Hasegawa et al. 1997).

Specific organ injury

Spleen

The spleen is the most commonly injured intraabdominal organ in the child. The mechanism of injury is usually blunt
trauma to the left upper quadrant, flank, or lower chest from a motor vehicle accident or fall. Physical examination will
usually elicit tenderness in the left upper quadrant. Unlike adults with a splenic injury, rib fractures are unusual. A
plain abdominal film may show the gastric bubble displaced to the right but a CT scan is the investigation of choice. In
most instances the spleen will bleed resulting in either free intraabdominal blood or be contained within a subcapsular
haematoma. The CT scan often looks dramatic but the key is to observe and act on the cardiovascular parameters
which allows over 90% of splenic lacerations to be successfully managed non operatively. Delayed splenic rupture
has only been very rarely reported. A vascular contrast blush seen on CT is however associated with arterial bleeding
and may be an indication for early laparotomy in children (Cox et al. 1997).

In subsequent days with non-operative management the child is often difficult to manage with delayed re-
establishment of normal feeding, some persistent abdominal pain, fever, and occasionally a pleural effusion. The
main clinical concern is: could there be an associated intraabdominal injury accounting for the persisting symptoms?
If there is any doubt then a repeat CT scan is indicated. It has been shown that with selective non-operative
management with careful observation the risk of missed associated injuries are minimal (Morse and Garcia 1994).

If operation is required efforts are made to preserve the spleen which may include spenorrhaphy, partial splenectomy,
or the use of an absorbable knitted bag to enclose the spleen (Aidonopoulos et al. 1995). This is important as it has
been shown that splenectomy caries a higher risk of death form overwhelming bacterial sepsis. This risk is highest in
the paediatric population. In the situation where splenectomy has to be performed, there has been some success in
splenic auto transplantation (Szendroi et al. 1997), although this does not guarantee protection from overwhelming
sepsis (Moore et al. 1983), as to preserve splenic function 25% of the spleen has to remain. It is therefore prudent to
immunize these children with polyvalent pneumococcal and Haemophilus influenza vaccine. It remains controversial
whether children should be on long-term penicillin or have an adequate stock at home to be started as soon as any
fever develops.
It is unclear how long one should restrict the physical activity of the child who has sustained splenic trauma. The rate
of healing as determined on serial CT scanning seems dependent on the original grade of splenic injury; with grade 1
and 2 injuries healing within 4 months, grade 3 injuries taking up to 6 months and grade 4 injuries taking up to 11
months (Benya et al. 1995). An uncommon sequelae of splenic trauma is the formation of a splenic pseudocyst.
Small cysts under 4cm often resolve spontaneously but larger cysts tend not to resolve and run the risk of infection,
rupture and haemorrhage. It is for these reasons that an operative approach be taken on large pseudocysts with the
aim at splenic preservation. Techniques include enucleation, marsupialization, and partial splenectomy but
sometimes these are not possible and splenectomy must be carried out (Teneriello et al. 1997).

Liver
In the last two decades the trend with children with liver injuries has also been to attempt non-operative management
if possible. This is because in children most hepatic injuries like splenic injuries will stop bleeding spontaneously.
Again the principles are of a detailed history working out the forces involved with intensive monitoring. It is important
when reviewing the literature on the management of liver trauma to appreciate that the denominator has changed in
many papers. With the advent of CT scanning many more minor liver injuries are being picked up. It is in such
population groups that operative rates of 7% have been reported. The same basic rules apply for liver injuries as for
any intrabdominal haemorrhage, that is if after a half blood volume replacement the child is still haemodynamically
unstable then operative intervention is indicated. If one has to operate then same techniques as used in adults such
as liver packing, blunt needle suturing and partial hepatectomy are indicated. A rare long-term sequela of hepatic
trauma in children is the formation of a hepatic cyst. While most of these are asymptomatic and can be managed
conservatively, occasionally can become symptomatic and require surgical intervention (Chuang et al. 1996).

Pancreas
Pancreatic injuries are uncommon in children. They usually occur as a result of blunt trauma to the upper abdomen
where an object has compressed the pancreas between itself and the vertebral column. Common scenarios include
injuries occurring from bicycle handlebars, go-cart steering wheels, and punch injuries often unfortunately as a result
of child abuse. Pancreatic injuries can present as a solitary finding or as part of multi intra-abdominal organ trauma. If
occurring in isolation the presentation is often delayed a few days with the child eventually presenting extremely
unwell with established pancreatitis. Trauma is responsible for between 15% - 37% all pancreatitis in children
Haddock et al. 1994, Synn et al. 1987, Weizman and Durie, 1988, Yeung et al. 1996, Ziegler et al. 1988). The key to
managing these injuries is to determine whether the main pancreatic duct is intact or not. When the duct is intact the
management should be non operative, but if transected then distal pancreatectomy is indicated (McGahren et al.
1995). Endoscopic retrograde pancreatography has been shown to be safe in children and clearly defines the main
pancreatic duct (McGahren et al. 1995, Richieri et al. 1994). CT scanning has improved the early detection of these
injuries but often will not have the resolution to demonstrate the status of the main duct. Serum and urinary amylase
will be elevated in pancreatic injury and levels are usually higher than found with isolated small bowel injury.

Pseudocysts will complicate acute pancreatitis in children in 10% - 23% of cases, but reaches up to 56% when due to
trauma (Haddock et al. 1994, Weizman and Durie, 1988, Yeung et al. 1996, Ziegler et al. 1988). When associated
with trauma up to 60% of pancreatic pseudocysts will require surgical intervention (Yeung et al. 1996). Surgical
options for the management of pancreatic pseudocysts in children include percutaneous drainage and open
procedures such as cyst-gastrostomy and cyst enterostomy (Poston and Williamson 1990). Endoscopic drainage
creating a cyst-gastrostomy with double pigtail catheters has been used successfully in the child with a post-traumatic
pancreatic pseudocyst (Kimble et al. 1999).

Intestinal

These are particularly problematic in children because they can be the result of minor abdominal trauma and early
physical examination and investigations may falsely reassure the clinician that there is no intraabdominal injury. The
key to management is to suspect the injury and perform serial physical examinations, noting increasing abdominal
tenderness, peritonism, tachycardia and fever. The mechanisms of injury that suggest bowel trauma include seat belt
injuries (especially lap belt), bicycle handle bar injuries, rapid deceleration, falls onto fences and rocks, and kicks or
punches (Newman et al. 1990, Clarnette et al. 1997). Small bowel injuries as a result of child abuse are particularly
difficult as they frequently present late with peritonitis and the history of the injury is often hidden or confused. A left
lateral decubitus abdominal x-ray is useful if it demonstrates free gas but if absent does not exclude the possibility
(Ulman et al. 1996, Ciftci et al. 1998). CT scanning will pick up many intestinal and mesenteric injuries (Ruess et al.
1997, Graham and Wong, 1996) however sometimes the signs are subtle such as focal bowel wall thickening, free
peritoneal fluid, and non-progression of the contrast material without demonstrating a leak (Cox and Kuhn, 1996).
However the gold standard remains serial physical examinations and if perforated bowel is suspected then
laparotomy is indicated (Albanese et al. 1996). Most bowel injuries can be managed with a primary anastomosis, but
occasionally a defunctioning ostomy is required (Ciftci et al. 1998).

Duodenal haematomas are fairly common following blunt abdominal trauma and present usually with discomfort and
bile stained vomiting. Non-operative management, which is quite often prolonged, is usually successful.

Penetrating injuries
The abdominal wall of a child is very thin. Therefore any object that penetrates through the skin must be assumed to
have entered the peritoneal cavity. The non-operative approach that applies to adults is less indicated in children and
should only be undertaken by experienced clinicians. All too often a small piece of glass, stick or piece of metal has
penetrated the peritoneal cavity and it is a safe policy if these injuries are seen infrequently, to explore the child and
fully ascertain the extent of the damage.