TRAUMATIC INJURIES
OF THE STOMACH
Abdominal trauma can cause serious injury to the stomach, small bowel, and colon. The nature and severity of the injury depend upon whether the injury mechanism is blunt or penetrating.
Blunt gastrointestinal injury may
result in crushing of the bowel between the body’s solid structures, such as
the spine or pelvis, and an external blunt force, such as a steering wheel,
seatbelt, or handlebar. Blunt gastrointestinal injury occurs more commonly in
the small bowel, followed by the colon and then the stomach. Rupture of the
stomach is relatively uncommon because of the stomach’s relatively protected
anatomic location.
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| Plate 4-41 |
Injuries of the stomach occur
relatively frequently with any penetrating or perforating wound of the abdomen,
as can occur with gunshots and knife stabbings. According to statistical data
of war surgery, about 8% of abdominal wounds involve the stomach, and in
approximately 5% the stomach alone is injured. With blunt trauma to the upper
abdominal region, the stomach may become lacerated, or it may even rupture if
the organ is filled and distended at the moment of impact.
The type of gastric wound produced
by a bullet or sharp instrument depends upon the size, shape, course, and
velocity of the wounding agent. Bullets that enter from the front, taking an
anteroposterior course, often cause only small perforations of the wall. Larger
shell fragments can produce rather extensive jagged lacerations, which
may completely sever the stomach from the duodenum, particularly if they
include the gastric antrum. Wounds of the cardia often involve the lower
end of the esophagus and mediastinum.
The clinical manifestations of any
perforating injury of the stomach are often very dramatic.
Depending upon the size of the wound, the loss of blood, and the presence or
absence of concomitant injuries, either shock or signs of peritonitis dominate
the clinical picture. Small perforations, causing little shock, may first cause
localized and then diffuse pain, which is soon followed by rigidity of the
abdominal wall, nausea, and vomiting of bloody material. The entry of air into
the abdominal cavity can be demonstrated radiologically. Small perforating
injuries of the cardia produce, in the beginning, very few or no clinical
symptoms. In most cases only left shoulder pain due to an inflammatory reaction
of the diaphragmatic peritoneum is present.
The prognosis of any gastric wound
depends upon the promptness of appropriate treatment, which is primarily
surgical intervention, rather than upon the type and degree of the injury. In
World War I, the mortality rate for all gastric wounds ranged between 50% and
60%, owing to the frequency of hemorrhagic shock and peritoneal infection, and
the rate for uncomplicated wounds restricted to the stomach ranged between 25%
and 50%. Much progress has been made since then in treating shock and
infection, including improved access to medical care with trauma centers,
resulting in a tremendous reduction in these mortality figures.
Treatment for injuries of the
stomach is primarily surgical, done at the earliest possible time. With both
gunshot and stab wounds, the posterior as well as the anterior wall may
be injured simultaneously, so that it becomes obligatory to explore
the posterior wall in every instance by adequately detaching the gastrocolic
ligament and pulling the stomach upward. Cases in which the anterior gastric
wall has remained intact and the posterior wall alone has been perforated, even
though the shot or puncturing instrument entered through the anterior abdominal
wall, have been reported. This can happen if, at the time of the accident, the
stomach was so tightly filled that the greater curvature, rotating around the
longitudinal axis of the stomach, has turned forward and upward. In this position
the inferior aspect of the posterior wall approaches the anterior abdominal
wall.
Extensive destructive wounds, with
major defects of the stomach, cannot be repaired and make a typical gastrectomy
or removal of large parts of the stomach inevitable.
If the cardia has been injured, a
left thoracotomy becomes necessary in order to ensure a sufficient view and
also freedom of action to perform a gastroesophageal resection in instances in which the esophagus also is found to be involved.
