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KEY POINTS

KEY POINTS

  • The normal stomach is relatively free of bacteria and other microorganisms because of the low intraluminal pH.

  • The thick-walled stomach is relatively resistant to blunt rupture except when it is full and the crash has high kinetic energy or there has been inappropriate placement of a lap seat belt.

  • The presence of an anterior penetrating gastric wound requires a thorough exploration of the lesser sac to identify the posterior wound.

  • A suspected “missing” gastric perforation from a gunshot wound mandates a provocative test by insufflating and distending the stomach with either air or saline down the nasogastric tube.

  • Because the stomach has an excellent blood supply, two-layer suture closures are performed to close perforations and injuries.

  • Hollow viscus injuries present in 1% to 3% of all blunt trauma patients, with small bowel injuries accounting for 90% of these injuries.

  • A transverse seat belt contusion (“seat belt sign”) across the abdominal wall carries an increased risk of injury to the small bowel and mesentery.

  • Modern computed tomography (CT) scans have improved the ability to diagnose injuries to the small bowel but can still be normal in 4% of patients with documented blunt rupture.

  • Free fluid on CT scanning without solid organ injury does not mandate laparotomy but does mandate close observation and serial examination.

  • Blunt ruptures of the small bowel, most often related to lap seat belts, most commonly occur near the ligament of Treitz or ileocecal valve or at the site of adhesions.

  • Delays in operation in patients with ruptures of the small bowel and stomach are associated with increased complications and death.

  • In patients with multiple small bowel injuries, the overarching concept is to leave as much bowel as possible with the smallest number of repairs and anastomoses.

  • The complication rate is similar for stapled and handsewn small bowel anastomosis.

  • Closure of an enterocutaneous fistula from prior repair of the small bowel is best accomplished with resection and anastomosis.

INTRODUCTION

Injuries to the stomach and small bowel are common following penetrating abdominal trauma. The incidence of gastrointestinal injury following gunshot wounds and stab wounds that penetrate the peritoneal cavity is in excess of 80% and 30%, respectively. Blunt injuries to the stomach and small bowel are much less common than penetrating injuries, but collectively compose the third most common type of blunt abdominal hollow viscus injuries (HVIs). Given these data, the trauma surgeon must be able to diagnose and treat these potentially life-threatening injuries.

The operative repair of injuries to the stomach and small bowel is relatively straightforward. The key to the successful management of stomach and small bowel injuries is prompt recognition and treatment, thus decreasing the likelihood of abdominal septic complications, including anastomotic leaks, fistulas, and intra-abdominal abscesses.

HISTORICAL PERSPECTIVE

Intestinal injuries were reported early in the medical literature, and small bowel perforation from blunt trauma was first reported ...

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