Abdominal Bruising Research Articles

Unique laparoscopic emergency management of traumatic obstructed abdominal wall hernia: A case report and review of literature

Abstract Traumatic abdominal wall hernia (TAWH) is a rare clinical occurrence, with only limited cases published since 1906. This type of hernia is primarily caused by low- or high-energy blunt force trauma, resulting in damage to abdominal wall musculature while the skin is intact. The diagnosis and management of TAWH poses a lot of challenges and complexities. Herein, we present a case of a 32-year-old male Saudi patient who sustained significant abdominal trauma as a driver involved in a front collision while wearing a seat belt. Upon arrival at the trauma center, the patient was hemodynamically stable and exhibited clinical signs of left flank bulge, seat belt sign, and abdominal bruising. First, a focused assessment with sonography for trauma (FAST) was performed, which revealed minimal free fluid in the abdomen. Subsequent contrast-enhanced IV computed tomography (CT) scan confirmed a 3.6-cm left lateral abdominal wall defect with herniation of short segments of the large and small bowel loops and adjacent subcutaneous fluid. Following initial observation, the patient developed signs of bowel obstruction. A repeat CT scan showed interval progression of the hernia, partial small bowel obstruction, and other concerning findings. An emergency laparoscopic exploration revealed a large defect at the left lumber region containing omentum and long segments of the small bowel with mild distension. The bowel and omentum were reduced. The surgical repair included herniorrhaphy and mesh placement. The patient recovered well and was discharged on the third postoperative day. This case underscores the importance of thorough evaluation and timely intervention in TAWHs. Rapid surgical management, aided by advanced imaging techniques, can lead to favorable outcomes even in complex cases involving bowel herniation and associated complications.

Female with Atraumatic Abdominal Bruising.

We describe the case of a 38-year-old female patient with a history of lupus presenting with atraumatic abdominal pain and ecchymosis. The ultimate diagnosis of abdominal lupus erythematous panniculitis was determined based on physical exam and imaging findings. Lupus erythematous panniculitis is a rare diagnosis, but consideration is important as early recognition and treatment is important to reduce pain and lessen the possibility of irreversible disfigurement and unnecessary costs to affected patients.

The acute abdomen in children

Because 8-10% of children in the emergency room present with acute abdominal pain, asystematic work-up is essential to rule out acute abdomen. This article highlights the etiology, symptoms, diagnostic workup, and treatment of acute abdomen in children. Review of the current literature. Abdominal inflammation, ischemia, bowel and ureteral obstruction, or abdominal bleeding are causes of acute abdomen. Extra-abdominal diseases such as otitis media in toddlers or testicular torsion in adolescent boys can also lead to symptoms of acute abdomen. Abdominal pain, (bilious) vomiting, abdominal guarding, constipation, blood-tinged stools, abdominal bruise marks, and poor condition of the patient with symptoms such as tachycardia, tachypnea, and hypotonia up to shock are leading symptoms of acute abdomen. In some cases, emergent abdominal surgery is needed to treat the cause of the acute abdomen. However, in patients with pediatric inflammatory multisystem syndrome temporarily associated with SARS-CoV‑2 infection (PIMS-TS), anew disease causing an acute abdomen, surgical treatment is rarely needed. Acute abdomen can lead to nonreversible loss of an abdominal organ, such as bowel or ovary, or develop into acute deterioration of the patient's condition up to the state of shock. Therefore, acomplete history and thorough physical examination are needed to timely diagnose acute abdomen and initiate specific therapy.

Woman with Abdominal Bruising

Woman with Abdominal Bruising

Conservative Management of Internal Bleeding Following Trauma in an Immune Thrombocytopenic Purpura Child with COVID-19 Infection

ABSTRACT Immune thrombocytopenic purpura (ITP) usually presents with minor bleeding such as petechiae and purpura. Rarely, life-threatening events such as intracranial and intra-abdominal bleeding can be occurred. Here, we present a case of a 9-year-old patient who presented to the emergency department after being hit by a motorcycle with a decrease of consciousness and symptoms of shock. On physical examination, a large abdominal bruise was seen, and it was proved by FAST to confirm abdominal bleeding. Sign of shock, decrease of hemoglobin, and a free fluid in Morison’s pouch were found by the FAST examination and led to establish abdominal bleeding diagnosis. The presence of bleeding in ITP patient, especially children, can be safely managed with observation alone. This case highlights the life-threatening condition, abdominal bleeding in severe thrombocytopenia, successfully treated with a conservative treatment strategy.

Things We Do for No Reason™: Toxic quizzing in medical education.

Things We Do for No Reason™: Toxic quizzing in medical education.

Improving the Diagnosis of Abusive Abdominal Trauma

Background/Objective: Abusive abdominal trauma (AAT) in children when missed can be fatal. In addition, differentiating from accidental trauma is essential in evaluating for other injuries and protecting from continued inflicted injuries. Abdominal CT remains the gold standard study to evaluate for abdominal injuries. Our purpose is to identify findings in presentation, clinical evaluation, the abdominal CT, and other imaging that can improve the diagnosis of abusive abdominal trauma.
 Methods: A retrospective (2011-2020) study compared children younger than 3 years that had abdominal CT scans for abusive trauma to those with accidental blunt abdominal trauma. Demographic information, clinical presentation, physical exam findings, final diagnoses, lab values, and imaging studies were collected. Descriptive analysis and Fisher’s exact test were used to determine significance of findings.
 Results: 226 (125 male, average age 11 months) patients had AAT and 90 (48 male, average age 18 months) patients had accidental trauma. 30 patients in the abusive group and 19 patients in the accidental group had positive CT. Most (70%) children with AAT and positive CT had no explanation for the trauma. Fall injury was reported in 27% of abusive (88.9% younger than 1 years) and 32% (83.3% older than 1 year) of accidental trauma. Retinal hemorrhage, abdominal bruising, subdural hematoma, and rib fractures were significantly (p<0.05) more common in the abusive group. In addition, 13 (43%) of patients with AAT and positive CT had rib fractures while none were detected on CT in the accidental group.
 Conclusions: In children younger than 3 years with abdominal trauma that present with a history of a fall or unknown injury, abusive abdominal trauma should be suspected. These children should subsequently be evaluated for other injuries. Children should be evaluated for nonaccidental trauma if rib fractures are visualized on abdominal CT, as these were only seen in AAT.

Post-traumatic renal artery thrombosis secondary to blunt abdominal trauma: a rare case report

Background: Blunt abdominal trauma is one of the leading causes of morbidity and mortality among populations worldwide. However, renal artery injury due to blunt abdominal trauma is a rare occurrence. In this case, a patient who suffered multiple trauma was found in the emergency department, including blunt abdominal trauma, after a motor vehicle accident.Case report: A 13-year-old boy with multiple trauma was referred to our emergency department, with the primary consideration being to lose consciousness 3 hours before admission due to a traffic accident. After receiving examination, there was no evidence of abdominal bruising, whereas the results of the head CT scan show epidural hemorrhage. After four days of treatment, the urea and creatinine serum levels increased, abdominal CT scan shows right renal infarction suggestive of right renal arterial rupture. The patient was diagnosed with a moderate head injury and right renal trauma AAST grade IV. The patient was referred to the interventional radiology unit. The endovascular revascularization techniques were performed with renal artery stent placement and vasodilator (nitroglycerin) flush into the renal artery before stent placement. Renal artery stenting placement performed on main right renal artery demonstrates the absence of intraluminal defects and substantially blood flow was established, abdomen CT Scan shows an enhancement on right renal parenchyma which mean right kidney vascularization appears to be improved with the return of glomerular filtration rate to normal value at the time the patient was discharged.Conclusion: Traumatic renal artery thrombosis is a rare occurrence with devastating consequences if any imaging is missed. Endovascular therapy plays a significant role in the treatment of renal artery thrombosis with a better prognosis.

Patterned abdominal wall bruise: An indicator of severe intra-abdominal injury.

Patterned abdominal wall bruise: An indicator of severe intra-abdominal injury.

Physical Examination is the Best Predictor of the Need for Abdominal Surgery in Children Following Motor Vehicle Collision

BackgroundExploratory laparotomy in children after motor vehicle collision (MVC) is rare. In the absence of definitive hemorrhage or free abdominal air on radiographic imaging, predictors for operative exploration are conflicting. ObjectiveThe purpose of this study was to explore objective findings that may aid in determining which children require operative abdominal exploration after MVC. MethodsData from 2010–2014 at an American College of Surgeons–certified level 1 pediatric trauma center were retrospectively reviewed. Demographics, vital signs, laboratory data, radiologic studies, operative records, associated injuries, and outcomes were analyzed and p < 0.05 was considered statistically significant. ResultsEight hundred sixty-two patients 0–18 years of age presented to the hospital after an MVC during the study period. Seventeen patients (2.0%) required abdominal exploration and all were found to have intraabdominal injuries. Respiratory rate was the only vital sign that was significantly altered (p = 0.04) in those who required abdominal surgery compared with those who did not. Physical examination findings, such as the seat belt sign, abdominal bruising, abdominal wound, and abdominal tenderness, were present significantly more frequently in those requiring abdominal surgery (p < 0.0001). Each finding had a negative predictive value for the need for operative exploration of at least 0.98. There were no significant differences in trauma laboratory values or radiographic findings between the 2 groups. ConclusionData from this study solidify the relationship between specific physical examination findings and the need for abdominal exploration after MVC in children. In addition, these data suggest that a lack of the seat belt sign, abdominal bruising, abdominal wounds, or abdominal tenderness are individually predictive of patients who will not require surgical intervention.

Blunt abdominal trauma in child: Epidemiological, diagnostic, and therapeutic analysis of 55 cases

Objective: The objective of this study was to report the epidemiological, diagnostic, therapeutic, and evolutionary aspects of blunt abdominal trauma in children. Patients and Methods: We carried out a descriptive retrospective study which collected between 55 children of victims of abdominal bruises and the children's surgery department of the Aristide Le Dantec hospital in Dakar between January 1, 2009, and December 31, 2015. The parameters studied were as follows: age, sex, circumstances and mechanisms, hemodynamic status, abdominal table, imaging, associated lesions, and treatment. Results: The mean age was 7.2 years. Boys were more affected with a sex ratio of 3.58. Road accidents were the most frequent cause of accidents with 50.9%. Thirty-six lesions of solid and hollow organs were recorded. The liver was the most affected organ (23.63% of patients), followed by spleen (9.1%) and kidney (7.3%). Multiple trauma was observed in 30.9% of patients with extra-abdominal lesions involving the thorax (64.7%), the skull (35.3%), and the pelvis (35.3%). Forty-seven patients (85.45%) received conservative treatment with a success rate of 93.62%; 11 patients (20%) underwent surgery. The overall morbidity rate was 14.54%, and mortality was 1.81%. Conclusion: Abdominal bruising in children is more common than wounds in the abdomen. Road accidents are the main etiology. Conservative treatment is in vogue in the service and gives very good results.

腹部打撲により破裂，出血した単純性肝囊胞に対し経カテーテル的動脈塞栓術を施行した一例

腹部打撲により破裂，出血した単純性肝囊胞に対し経カテーテル的動脈塞栓術を施行した一例

Intraductal papillary mucinous neoplasm of the pancreas spontaneously ruptured into the peritoneal cavity.

A 72-year-old female was pointed out to have a dilated main pancreatic duct of the pancreatic body and tail and fluid collection around the spleen by ultrasonography performed for annual medical check. She did not have any sign of abdominal and/or back pain, and had no history of abdominal bruising. Computed tomography demonstrated the main pancreatic duct dilatation that was 12 mm in size, and the accumulation of fluid around the pancreatic tail and the spleen. The dilated main pancreatic duct was apparently continuouswith the extrapancreatic fluid (Fig. 1). Magnetic resonance cholangiopancreatography also revealed distal pancreatic duct dilatation and communicating fluid collection around the spleen (Fig. 2). Endoscopic ultrasonography revealed the distal pancreatic duct dilatation and mural nodules with 5 mm in size. Based on these findings, main duct type intraductal papillary mucinous neoplasmwith pseudomyxoma peritonei caused by spontaneous rupture into the peritoneal cavity was highly suspected. At laparotomy, yellow-tan gelatinous material was encountered around the pancreas tail and the spleen (Fig. 3). Additionally, lavage cytology at Douglas’ pouch was positive for mucus, although no cancer cells were observed in the specimen. Therefore, we considered that, microscopically, mucus spread diffusely to entire abdominal cavity. After removal of the extrapancreatic mucus, distal pancreatectomy and splenectomy were performed. Intraperitoneal lavage using 10 000 ml of dextran fluid was also performed. Macroscopically, the resected specimen revealed a 15 mm orifice and mucus outpouring at the pancreas tail (Fig. 4). Pathologically, the tumor was diagnosed as minimally invasive intraductal papillary mucinous carcinoma without lymph node metastasis. After surgery, she received adjuvant chemotherapy with S-1 and survived for 1 year without any sign of recurrence. Figure 1.

Method for investigation of child occupant impact dynamics based on real-world accident

The objective of the study is to propose a method to investigate child occupant impact dynamics based on realworld accident reconstruction. A real-world child occupant accident was reconstructed by using PC-Crash and finite element (FE) modeling software, with the aim of comparing simulation output with injuries sustained. Firstly, PC-Crash reconstruction was carried out to calculate vehicle impact conditions of vehicle impact velocity, vehicle position and vehicle orientation. The dynamics responses at the head, neck, thorax and pelvis of the child occupant were simulated. Hybird III 6-year-old FE model was employed in FE simulation. The results of two vehicles’ positions agreed well with that in real-world accident case, the dynamics responses at the head, neck and thorax of the child occupant well indicate the injury status of the child occupant. The simulation results showed that booster seat headrest and intrusive door mainly causes head injuries and seat belt mainly causes abdominal bruise of children. This study provides a useful method to investigate the impact dynamic and injury risk of child occupantre.

A systematic review of abusive visceral injuries in childhood—Their range and recognition

ObjectivesTo define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children. MethodsWe searched 12 databases, with snowballing techniques, for the period 1950–2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0–18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome. ResultsOf 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5–3.7 years vs. 7.6–10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with ‘negative’ screening tests were not consistently investigated. ConclusionsVisceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.

A 60-year-old man with abdominal bruising

A man with liver cancer developed abdominal ecchymoses resembling the Cullen sign and flank ecchymoses resembling the Grey Turner sign.

Utility of Hepatic Transaminases to Recognize Abuse in Children

Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken. Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4-4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.

Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes

Background Children involved in motor vehicle crashes (MVC) can sustain bruising of the abdominal wall associated with seat belt restraint. The incidence of bruising and its relationship with significant intraabdominal injuries are not known. Methods An analysis of children involved in MVC between December 1998 and November 2002 was performed, using the crash surveillance database from the Partners for Child Passenger Safety (PCPS) project. Optimally (OR) or suboptimally (S-OR) restrained children aged 4 to 15 years were selected. The incidence of abdominal wall bruising was calculated then correlated with the type of restraint as well as any intraabdominal injury with an Abbreviated Injury Scale score ≥2. Results A total of 147,985 children in 102,548 crashes met study criteria. An abdominal bruise was noted in 1.33% of the children (n = 1,967; 881 OR and 1,086 S-OR). Significant intraabdominal injury was present in 309 children (0.21%, 95% CI 0.13 to 0.33), including 69 OR and 240 S-OR. The sensitivity, specificity, and positive and negative predictive values of abdominal wall bruising for a significant intraabdominal injury were 73.5%, 98.8%, 11.5%, and 99.9%, respectively. Children with a bruise were substantially more likely to have an intraabdominal injury than children without a bruise. (Odds Ratio 232.1, 95% CI, 75.9 to 710.3) Among those children with an abdominal bruise, 1% required an abdominal operation (n = 20). Conclusions Abdominal wall bruising was relatively uncommon in both OR and S-OR children. Among restrained children involved in MVC, those with a bruise were 232 times more likely to have a significant intraabdominal injury when compared with those without a bruise. It is imperative to pursue intraabdominal injury in children with a bruise of the abdominal wall after MVC.

Identification of physician and patient attributes that influence the likelihood of screening for intimate partner violence.

Effective assessment of intimate partner violence (IPV) demands that everyone at risk be screened. To identify potential barriers, paper-and-pencil case scenarios identified possible practitioner and patient attributes that influence IPV screening. First-year residents responded to one of four short written scenarios describing a divorced female patient with nonlocalized abdominal pain; variables were patient's age and abdominal bruising. Residents rated their likelihood of screening for IPV and seven other screening tasks and self-assessed their competence in performing each task. Regression analyses assessed the influence of resident and patient characteristics on screening likelihood. Patient bruising, younger patient age, and resident self-assessed competence best predicted IPV screening. Men were less likely than women to screen for IPV. Although most physicians receive training on IPV in medical school, barriers to IPV screening still exist. Identifying obstacles to IPV risk-assessment is an essential prerequisite for improving educational programs that promote routine IPV screening.

Bruising in non-accidental head injured children; a retrospective study of the prevalence, distribution and pathological associations in 24 cases

Non-accidental head injury, be it shaking, impact(s) or a combination of the two, is characterised by subdural and/or subarachnoid haemorrhages with retinal haemorrhages, but minimal or absent external cranio-facial trauma. The classical assault scenario depicts the infant being gripped around the head, face, chest and abdomen and shaken or being gripped by a limb and swung. This gripping might be expected to leave physical evidence in the form of bruising. A study was undertaken to establish the prevalence, distribution and pathological association of external bruising in 24 cases of fatal non-accidental head injury in children. At autopsy, 17 cases had new external bruises, 15 old external bruises and 13, a combination of both. However, seven (29%) cases showed no fresh external bruising and five (21%) showed no external bruising at all. Thus, external bruising may be absent in children with fatal intracranial injury. The face was shown to be the commonest site of bruising followed by the forehead and buttocks. Limb, chest and abdominal bruising were found to be uncommon. Retinal haemorrhages were confirmed in 23 (96%) cases. It is hypothesised that bruising, when present, may be a result of abuse in the form of punches and slaps rather than due to gripping during the assault. We discuss why gripping does not necessarily result in external bruising.