perforasi gaster

Gastric rupture from blunt abdominal trauma

Eva Esther Tejerina Alvarez*, Mar½a Soledad Holanda,Francisco Lopez-Espadas, Maria Jose Dominguez,Elsa Ots, Jenaro D½az-Reganon

Unit of Multisystem Trauma, Department of Intensive Medicine, Marques de ValdecillaHospital of Santander, Cantabria, Spain

Accepted 25 May 2003

Introduction

Gastric rupture following blunt abdominal trauma israre and large series in the literature report anincidence between 0.02 and 1.7%.4—7,10,18,19,21,22

Road traffic accidents remain the most frequentcause of gastric rupture and count for about 75%of patients. The mortality rate ranges from 0 to66%,4—7,10,18,19,21,22 and is mostly related to asso-ciated injuries. The factors most often implicatedare: a history of a full stomach or recent meal,trauma to the left side of the body and aninappropriate use of seat belts. Splenic injury is

generally the most common associated injury, fol-lowed by thoracic injury. The high morbidity andmortality associated with gastric rupture aredirectly related to associated injuries, delays indiagnosis and intraabdominal septic complications.

The purpose of this study was to review cases ofgastric rupture from blunt abdominal trauma and itsassociated characteristics in our intensive care unit.

Material and methods

We performed a retrospective study of 1300patients with blunt trauma to the abdomen treatedin our intensive care unit during the 28-year periodfrom 1973 to 2001. Seven patients sustained agastric rupture (five men and two women). The

Injury, Int. J. Care Injured (2004) 35, 228—231

KEYWORDS

Gastric rupture; Blunt

abdominal trauma;

Road traffic accidents;

Seat belts; Deceleration;

Splenic injury;

Thoracic trauma;

Intraabdominal sepsis;

Chemical peritonitis;

Peritoneal lavage

Summary Gastric rupture following blunt abdominal trauma is rare, with a reportedincidence of 0.02—1.7%. Road traffic accidents remain the most frequent cause. Thefactors most often implicated in the genesis of this entity are: a history of a recentmeal, trauma to the left side of the body and an inappropriate use of seat belts. Splenicinjury is generally the most common associated injury. The high morbidity and mortalityare directly related to the number of associated injuries, delays in diagnosis and thedevelopment of intraabdominal sepsis. We performed a retrospective study of 1300patients with blunt trauma to the abdomen from 1973 to 2001. Seven patients sustaineda gastric rupture (five men and two women). The following associated characteristicswere analysed: mechanism of injury, clinical presentation, possible associated injuriesand postoperative complications, diagnosis methods and surgical treatment. We foundan incidence of gastric rupture of 0.5%. We emphasise an early diagnosis and aggressivesurgical treatment as a key to decreasing the mortality and morbidity from this injury.However, in our series, the morbidity is mainly from associated injuries.� 2003 Elsevier Ltd. All rights reserved.

*Corresponding author. Tel.: þ34-91-5399504/658-771710;fax: þ34-942-203543.

E-mail address: [email protected](E.E. Tejerina Alvarez).

0020–1383/$ — see front matter � 2003 Elsevier Ltd. All rights reserved.doi:10.1016/S0020-1383(03)00212-2

following associated characteristics were analysed:mechanism of injury, clinical presentation, possibleassociated injuries and postoperative complica-tions, diagnosis methods and surgical treatment.

Results

The clinical results of the patients with gastricrupture are shown in Table 1.

Discussion

We found seven gastric ruptures in 1300 patientswith blunt abdominal trauma, an incidence of 0.5%and with a mortality rate of 0%. Several publishedseries4—7,10,18,19,21,22 reported an incidence of gas-tric rupture from blunt abdominal injury of 0.02—1.7%, as shown in Table 2.

Although some authors18 find that the incidenceis higher in childhood, other reported series4,21

failed to demonstrate such a correlation withage. Males were injured four times as frequentlyas females.22 In our series, males were involved infive cases of gastric rupture (71.4%), with an aver-age age of 31.8 years (range from 9 to 46 years).

Road traffic accidents are the most importantcause of gastric rupture from blunt trauma and wereinvolved in nearly 75% of the patients.4 In the pre-sent series, motor vehicle accidents account for85.7% of gastric tears. Other causes are falls, directviolence, cardiopulmonary resuscitation and seat-belt injury.4,8,21. Most reported abdominal injuriesare associated with lap belts, often worn incor-rectly.1,2,8,12,15 Spontaneous rupture may also occurin adults after an excessive consumption of food,liquids or sodium bicarbonate.22

The stomach is a thick-wall, muscular and capa-cious organ with a relatively protected anatomicalposition and a high degree of mobility, so it isrelatively resistant to a blunt injury, particularlywhen empty. However, when the stomach is dis-tended, as by a recent meal, blunt trauma to the

Table 1 Clinical results of the patients with gastric rupture

Characteristics Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7

Age (years) 7 24 33 29 48 42 40Sex Female Male Male Male Female Male MaleAPACHE II Unknown 14 9 11 8 Unknown 9Mechanism

of injuryBeaten bythe snoutof a cow

Motorvehicleaccident






Symptomsand signs

Peritonealirritation


Abdominalpain

Abdominalpain

Abdominalpain


Thoracicpain

Hematomain lefthemithorax

Hematomain left lowerquadrant

Shock Haematemesis Thoracic pain Shock Haematemes

Shock

Shock Peritonealirritation

Diagnosticmethod

Pneumoperitoneumon X-ray

Laparotomy PL: positive PL: positive PL: positive PL: positive Pneumoperitoneumon X-ray

Associatedinjuries

No Spleenlaceration

Pancreaticsection

Spleenrupture

Spleenlaceration

Serosal tear of thetransverse colon

Bilateral lungcontusion

Lefthemidiaphragmrupture

Liverlaceration

Rightretroperitonealhematoma

Right femurand fibulafractures

Leftretroperionealhematoma

Myocardialcontusion

Pelvis fracture Retroperitonealhematoma

Pelvis fracture Head injuryLeft rib fracture

Myocardialcontusion

Head injury Head injury

Site of ruptureand otherfindings

Lesser curvature Anterior wall Posterior wall Posterior wall Anterior wall Anterior andposterior wall

Anterior wallGastric contentsin abdominalcavity

Gastric contentsin abdominalcavity

Gastric contentsin abdominalcavity

Complications Left pleuraleffusion

Left pleurisy Intraabdominalabscess

No No Intraabdominalabscess

No

Mortality No No No No No No NoLength of stay

in UCI (days)6 9 17 6 2 25 7

Length of stay inhospital (days)

10 13 96 19 8 56 13

PL: peritoneal lavage; MOSF: multiorgan system failure.

Gastric rupture from blunt abdominal trauma 229

upper abdomen can lead to an increase in intragas-tric pressure sufficient to cause rupture. Accordingto Law of Laplace (P ¼ T=R), wall tension is highestin the parts of the stomach with the greatest radiusof curvature, such as the anterior wall and greatercurvature, predisposing them to rupture.4,9,22 Inseveral published series,4,13,18,19,21,22 a history ofrecent meal prior to gastric rupture is significantlyrelated to this injury, with a reported incidence of27—76%. In our series, only one patient had a fullstomach just before injury.

Tearing by deceleration has been postulated asother possible mechanism of injury to the stomachdirectly related with the use of lap-belt-stylerestraining devices.2,8,9,12,14,15 Lap belts aredesigned to be worn at or below the level of theanterior superior iliac spines, but have a tendencyto ride up over the abdomen. In this location, asudden deceleration may cause abrupt and directcompression of the stomach between the seat belt,the posterior abdominal wall and the rigid spinalcolumn. Lap and shoulder types of belts spread thedeceleration over a larger area so that they shouldbe less likely than lap belts to cause direct compres-sion injury of abdominal viscera.2,8,14 Decelerationalso generates shearing forces at the relatively fixedjunction of the pylorus and duodenum and a simul-taneous rapid forward motion of the stomach. Thislast mechanism appears more likely in the case ofgastric rupture associated with the lap belt. In ourstudy, only one patient was wearing seat belt whenhe was involved in a road traffic accident, but it isunknown what type of seat belt he used.

The majority of patients either present in shock orwith signs and symptoms of an acute abdomen,mainly as a result of the chemical peritonitis inducedby the spillage of gastric acid.3,4,11,13,18,20—22 In thepresent series, the most frequent clinical findingswere abdominal pain, peritoneal irritation and shock(42.8%), followed by haematemesis and haematomaon the left side of the body (28.5%), which seem to bemore specifically related to gastric rupture. Subcu-taneous emphysema may appear via the mediasti-num when rupture occurs near the cardioesphagealarea.13,18,22 Free intraperitoneal air on abdomen andchest films may be absent in 29.4—83.3% of the

cases.4,6,18,19,21 This may be attributable to the factthat most trauma patients have radiographic exam-inations performed while in the supine position. Inour series, there was a pneumoperitoneum in fivecases (71.4%). Aspiration of a dark peritoneal lavagefluid by the action of gastric acid on haemoglobin, aturbid fluid as well as thepresence of bile or amylase,may suggest gastric rupture.4,16,17,21 In the presentstudy, haemoperitoneum was suspected on clinicalfindings and was confirmed with a positive peritoneallavage in four patients. Ultrasound may be useful todetect abdominal fluid. CT-scan is especially valu-able if the diagnosis of gastric rupture is delayed.1,20

Splenic injury is generally the most commonassociated injury, followed by significant thoracicinjuries, mainly to the left side of the body.4,16,17,21

Thoracic trauma is a major contributing factortowards substantial morbidity and mortality asso-ciated with gastric rupture.4,9 Splenic injury waspresent in three of our patients (42.8%), trauma toleft side of the body was present in four patients(57.1%) and thoracic trauma to this same side in twopatients (28.5%).

The majority of complications are directlyrelated to the massive intraperitoneal contamina-tion with undigested food and gastric acid, causing achemical peritonitis.6,16,20 Delay in diagnosisincreases the period of peritoneal contaminationand adds to the mortality.1,21 The most commoncomplication is intraabdominal abscess formation.Gastric fistulae may also occur. Two of our patients(28.5%) developed intraabdominal abscesses.

Blunt gastric rupture can occur in any portion ofthe stomach. It usually occurs as a single lesion,which is commonly debrided and repaired by pri-mary closure. It is unusual a gastric rupture withextensive damage requiring partial gastrect-omy.16,19 The anterior gastric wall is most ofteninvolved, reported to be 40% in the reviewed lit-erature,4,6,18,22 as shown in Table 3, followed bygreater curve (23%), lesser curve (15%), and poster-ior wall (15%). However, the greater curvature is thesite most often affected in the paediatric agegroup.21 The injury occurs more commonly on a fullstomach leading to peritoneal contamination withsolid food particles as had occurred in three of our

Table 2 Incidence and mortality of gastric rupture in several published series

Series Incidence of hollowvisceral injury (%)

Incidence of gastricrupture (%)

Mortality (%)

Yajko and associates (1930—1975): 37 cases 11—18 0.9—1.7 47Semel and Frittelli (1975—1981): 17 cases 12Courcy and associates (8 years): 6 cases 2.9 0.4 0Bransting and Morton (10 years): 6 cases 50

230 E.E. Tejerina Alvarez et al.

cases. In the present series, the anterior wall of thestomach is the most common site of rupture (57.1%),Similar to other reviewed series, followed by poster-ior wall (42.8%) and lesser curve (14.2%). In ourseries, greater curve was not affected in any patient.

Some authors recommend adequate debridementof the margins of the laceration and a postoperativegastric decompression is also advised. It is alsoimportant to inspect the entire surface of the sto-mach, even the posterior surface. To prevent theoccurrence of an intraabdominal abscess the abdom-inal cavity needs an extensive mechanical irrigationwith large amount of a diluted solution of beta-dine.6,20. In the case of abscess formation, an aggres-sive approach of early reoperation and drainage isemphasised.4,19,20 Primary gastric closure was per-formed in all seven patients in our series.

The mortality associated with gastric rupture hasbeen reported to range from 0 to 66%.4—7,10,18,19,21,22

It is mostly related to associated injuries, septiccomplicationsand, less frequently, to fatal shock.4,17

In the present study, we observed a mortality rateof 0%.

Conclusions

We report an incidence of gastric rupture of 0.5% ofall blunt trauma admissions in our unit, similar tothat seen in the reviewed literature. We agree withother authors in emphasising an early diagnosis andaggressive surgical treatment as a key to decreasingthe mortality and morbidity from this injury. How-ever, in our series, the morbidity is mainly fromassociated injuries.

References

1. Allen GS, Moore FA, Cox CS. Hollow visceral injury and blunttrauma. J Trauma 1998;45:69.

2. Baker AR, Ferry EP, Fossard DD. Traumatic rupture of thestomach due to seat belt. Injury 1986;17:47.

3. Bergquist D, Hedelin H, Karlsson G. Upper gastrointestinaltrauma. Acta Chir Scand 1981;147:637—43.

4. Brunsting LA, Morton JH. Gastric rupture from bluntabdominal trauma. J Trauma 1987;27:887.

5. Clarke R. Closed abdominal injuries. Lancet 1954;2:877—85.6. Courcy PA, Soderstrom C, Brotman S. Gastric rupture from

blunt trauma. A plea for minimal diagnostics and earlysurgery. Am Surg 1984;50:424.

7. Cox EF. Blunt abdominal trauma, a 5-year analysis of 870patients requiring celiotomy. Ann Surg 1984;199:467—74.

8. Dajee H, Macdonald AC. Gastric rupture due to seat beltinjury. Br J Surg 1982;69:436.

9. Dharap SB, Murthy BNS, Sheth HB. Gastric rupture fromblunt abdominal injury. Injury 1996;27:753.

10. Fitzgerald JR, Carwford ES, Debakey ME. Surgical considera-tions of non-penetrating abdominal injuries: an analysis of200 cases. Am J Surg 1960;100:22—9.

11. Hockerstedt K, Airo L, Karaharju E, Sundin A. Abdominaltrauma and laparotomy in 158 patients. Acta Chir Scand1982;148:9—14.

12. Kimmins MH, Poenaru D, Kamal I. Traumatic gastrictransection: a case report. J Pediatr Surg 1996;31:757.

13. Knottenbelt JD, Van As S, Volschenk S. Gastric rupture fromblunt trauma: two unusual presentations. Injury 1993;24:65.

14. Lopez-espadas F, Iribarren JL, Morrondo P. Lesionesasociadas al cinturon de seguridad. Cir Esp 1998;63:40.

15. Mukerjea SK, Nair KK. Seat belt injury causing pneumothor-ax with rupture of diaphragm, stomach, and spleen. Lancet1978;11:1044.

16. Nanji SA, Mock C. Gastric rupture resulting from bluntabdominal trauma and requiring gastric resection. J Trauma1999;47:410.

17. Salvado J, Lopez-espadas F, Varela A. Rotura gastrica comocomplicacion del traumatismo abdominal cerrado. MedIntens 1977;1:51.

18. Semel L, Fritelli G. Gastric rupture from blunt abdominaltrauma. NY State J Med 1981;81:938.

19. Siemens RA, Fulton RL. Gastric rupture as a result of blunttrauma. Am Surg 1977;43:229—33.

20. Theunis P, Coenen L, Brouwers J. Gastric rupture from bluntabdominal trauma. Acta Chir Belg 1988;88:309—11.

21. Vassy LE, Klecker RL, Koch E, Morse TS. Traumatic gastricrupture in children from blunt trauma. J Trauma 1975;15:184—6.

22. Yajko RD, Seydel F, Trimble C. Rupture of the stomach fromblunt abdominal trauma. J Trauma 1975;15:177.

Table 3 Site of gastric rupture in several published series

Series Anteriorwall (%)

Greatercurvature (%)

Lessercurvature (%)

Posteriorwall (%)

Yajko and associates (1930—1975): 37 cases 26 16 32 11Semel and Frittelli (1975—1981): 17 cases 53 29 6 12Courcy and associates (8 years): 6 cases 33 33 0 33Brunsting and Morton (10 years): 6 cases 60 20 0 20

Gastric rupture from blunt abdominal trauma 231

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