Blunt and penetrating abdominal injuries (a study of 51 cases).
In an age of speed, civil violence, armed conflicts, crimes of passion and traffic accidents, the incidence of penetrating and blunt injuries to the abdomen has been on the increase. Although, he morbidity and mortality from these injuries are gradually decreasing, abdominal injuries still pose a formidable problem, especially in young adults, not only in terms of hemorrhage and infection but also regarding early diagnosis.
The present study is based on 51 cases of penetrating and blunt abdominal injuries collected from 1st April 1980 to 30th September, 1981 in our hospital. Out of these 51 cases, 44 were males and 7 females. Thirteen patients were below 20 years of age and 36 belonged to the third decade. One case each belonged to the 4th and 5th decades.
Blunt trauma was responsible for 26 cases and penetrating injuries for 25 cases. The highest number of cases with blunt trauma (11) were due to vehicular accidents. Eight cases had a fall from height; three had a fall while walking. Three cases had an assault with a blunt object and one case had a fall of weight on the abdomen. Of the 25 cases with penetrating injuries, 24 were due to stab wounds. Only one case of gun shot wound was recorded. The wounds of entry of penetrating injuries are shown in [Fig. 1] In 21 of these 25 cases, the injuries were single. In the remaining 4 cases, there were multiple stab wounds. Viscera protruded through the stab wounds in 6 cases.
The average time elapsed before admission was about 7 hours. One patient was admitted as early as 30 minutes after injury whereas the longest period was 72 hours as the patient refused to seek medical treatment.
Pain was present in all the 51 cases. Vomiting was noted in 13 cases. Distension of abdomen was observed in 4 cases and all these were found to have visceral injuries at operation. Physical findings noted in these cases are shown in [Table - 1]
Radiography was performed in 33 cases. Seven showed positive results; five had gas under diaphragm, one had multiple fluid levels and one had a foreign body (bullet). Peritoneal tapping was done in 34 cases out of which 27 were positive. There were two cases of false negative tap; however, laparotomy was carried out because of peritoneal deep stab wounds. One patient had a jejunal tear and the other had a mesenteric tear.
Of the 10 cases with hollow visceral injury, in five cases, there was no gas under the diaphragm; thus absence of gas under diaphragm does not rule out hollow visceral injury.
Exploratory laparotomy was performed in 47 cases; 4 cases were kept under observation for 3-4 days. The indications for operations were (a) protrusion of viscera, (b) signs, of peritoneal irritation, (c) blood in nasogastric tube, (d) positive peritoneal tap, (e) peritoneal penetration and (f) X-ray showing gas under diaphragm. Out of 47 cases undergoing laparotomy, 44 had visceral injury involving various organs [Table - 2]
The operative procedures adopted in our patients are shown in [Table - 3]
The complications encountered were minor wound infection in seven cases, burst abdomen in one, post-operative obstruction in one, gastric and faecal fistulae in one case each and chest infection in two cases.
Ten patients died in the present series. Out of these, five had peritoneal sepsis, three had bronchopneumonia, one had left subphrenic abscess and another had hemorrhagic shock with cardiac arrest.
The maximum incidence of abdominal injuries occurred in the 2nd and 3rd decades. Males were affected more frequently. Blunt trauma and penetrating injuries were responsible in almost equal numbers. All our patients were pedestrians. In a series by DiVincenti et al, more than 2/3rds of the cases were due to traffic accidents.
In the penetrating injury group, stabbing was responsible for 96% of cases and was in the epigastric region. Only one case of gun shot wound was recorded in our series. These injuries are very common in the western countries., , 
In 70% of blunt trauma cases, there was no external injury and hence much reliance was placed on clinical judgement and investigations. Absent bowel sounds and abdominal wall rigidity were the most sensitive indices as their presence was always associated with intraperitoneal injury. Protrusion of viscus formed a definite indication far laparotomy, as was also in other series.,,,
Whenever possible, cases were subjected to radiological examination of the abdomen and chest in the standing position. However, negative radiological examination does not rule out hollow visceral injury., 
Abdominal paracentesis should be carried out in all cases which present diagnostic problems.,  In our series, intra abdominal injury was detected in all 24 cases with positive peritoneal tap. However, in two cases the tap was false negative.
All the six cases with peritoneal penetration were subjected to laparotomy. In three of these, there was no visceral injury.
In our series, liver was found injured most frequently followed by jejunum and spleen. Nance and Cohn had also found liver being commonly injured followed by small bowel. Massive bleeding from liver was controlled by Pringle's manoeuver or packing of the wound.
Wound infection (treated conservatively) and chest infection were the common complications. Patients responded to chest physiotherapy and antibiotics. Nance et al and Stein and Liscoss have also shown wound and chest infections as the commonest complications in their series.
There was 20°Jc mortality in our series mostly due to peritoneal sepsis followed by bonchopneumonia and haemorrhagic shock. DiVincenti et al had 23% mortality. Stein and Liscoss reported 3.8% mortality and peritonitis was the commonest cause of death followed by pneumonia.
(1) Blunt trauma and penetrating injury were responsible for equal number of patients, the highest number of blunt trauma being due to vehicular accidents; only one of the penetrating injury was due to bullet injury.
(2) Negative radiological examination does not rule out a hollow viscus injury.
(3) A negative peritoneal tap does not exclude an intra-abdominal injury.
(4) The delay between the time of injury and the initiation of treatment is responsible for the unfavourable outcome.
(5) Persistent sepsis is responsible for higher mortality.
We thank Dr. C. K. Deshpande, Dear, K.E.M. Hospital, Bombay, for permitting us to report the hospital data.