C H A P T E R 1 6 
Abdominal and Renal Trauma
Barbara A. Gaines  •  Kelly M. Austin
While head injuries are responsible for the majority of
pediatric trauma deaths, intra-abdominal and retroperi-
toneal injuries can still result in significant morbidity and
mortality. Diagnostic uncertainty and delays in diagnosis
can lead to long-term complications and adversely impact
quality of life. Injuries to intra-abdominal organs occur
in 10–15% of injured children.1 The spleen is the most
frequently injured organ, and low velocity mechanisms,
such as falls, is the most frequent mechanism of injury.
The combination of the unique anatomic and physiologic
features of children and differences in mechanism result
in patterns of injury unique to the pediatric population.
As just mentioned, falls are the most frequent mecha-
nism of injury in children. However, motor vehicle
crashes (MVC) are the most deadly, and are the leading
cause of death for all children after the age of 1 year.2
From the perspective of abdominal trauma, and using the
spleen as a marker for intra-abdominal injury, pediatric
injuries tend to be the result of lower-velocity mecha-
nisms when compared to adults. In a study that compared
splenic injuries at an adult level one trauma center and a
pediatric level one trauma center, MVC accounted for
66.9% of adult injuries but only 23.7% of pediatric inju-
ries.3 On the other hand, ‘sports mishaps’ resulted in only
2.3% of the adult injuries, but 17% of injuries involving
children. Even in the MVC population, pediatric injuries
tend to differ from those suffered by adults. Children are
less likely to be in the driver’s seat (and hence less likely
to suffer injuries to the thorax from the steering wheel),
and are more likely to be victims of poorly fitted restraint
systems. It is an important part of the initial history to
ascertain whether the pediatric victims in an MVC were
restrained, and the type and appropriateness of that
restraint for the child’s age.
Anatomically, the smaller size of children, as compared
to adults, results in a closer proximity of organs. The
abdominal wall, rib cage, and pelvic girdle are underde-
veloped and provide less protection to the abdominal
contents. In addition, children have less body fat, and
hence, less ‘padding’ to absorb and diffuse external
force.4 From the physiologic perspective, children
are generally healthy and have fewer underlying
medical problems than adults. It is uncommon for chil-
dren to be on medications, particularly those that poten-
tially affect hemodynamics or hemostasis. Therefore,
injured pediatric patients are better able to effectively
compensate for physiologic insults such as acute blood
loss. It is generally accepted that children can lose up
to 45% of their circulating blood volume, and exhibit
tachycardia as the only abnormal vital sign.4 Persistent
hypotension is an ominous finding, suggesting the
failure of compensatory mechanisms and the potential
200
development of irreversible shock. Complicating the
evaluation of injured children is the normal variability of
vital signs depending on age.
INITIAL EVALUATION AND DIAGNOSIS
OF ABDOMINAL INJURIES
As the number of children with significant abdominal
injuries is relatively low, but the consequences of a missed
injury are high, accurate diagnosis is important. Initial
assessment begins before the child arrives at the hospital.
Important information from the first responders includes
mechanism of injury, use of protective or restraint devices,
condition of the child in the field, and, in the case of
MVC, damage to vehicle. Once in the emergency depart-
ment (ED), a thorough history and physical examination
is essential. In most statistical models regarding the diag-
nosis of intra-abdominal injury, an abnormal physical
examination is the highest variable.5–8 While the exami-
nation can be challenging given the developmental level
of the child, use of comfort strategies and distraction can
calm an initially distraught child to a degree that he/she
can reliably participate in the evaluation. Important phys-
ical findings include vital signs (particularly the presence
of persistent tachycardia), abdominal contusions or abra-
sions, tenderness, or distention. Particular physical find-
ings, such as the ‘seat belt sign’ and ‘handle bar mark,’
are suspicious for the presence of intra-abdominal injury
(and potential spine fracture in the case of the seat belt
mark) (Fig. 16-1).9
Laboratory Testing
Laboratory testing for the purpose of diagnosing intra-
abdominal injuries has generated considerable interest
and conflicting results. One study reported that the com-
bination of an abnormal physical examination and >50
red blood cells per high power field on urinalysis was a
highly sensitive screen for the presence of intra-abdominal
injury.5 The study, limited by the low number of children
who actually had a documented injury (14 out of the total
study population of 285), also concluded that laboratory
abnormalities in this trauma population were relatively
uncommon. The conclusion that routine laboratory
studies add little to the evaluation has also been replicated
in more recent studies.6,7 Conversely, studies using
sophisticated regression analyses have demonstrated that
elevations of aspartate aminotransferase (AST) and/or
alamine aminotransferase (ALT), in combination with an
abnormal physical examination, correlate with the pres-
ence of an intra-abdominal injury, although the tests are

A B
not diagnostic for a particular injured organ.8,10–12 A clini-
cal prediction model using a combination of physical
examination findings (hypotension and abnormal exami-
nation findings) and laboratory studies (AST, amylase,
hematocrit, heme-positive urinalysis) successfully pre-
dicted the presence of intra-abdominal injury in a
small, single center study.13 Interestingly, routine amylase
and lipase determinations do not appear to be very reli-
able or cost effective screening tools.14 In the special
population of children suspected of abuse, elevations in
AST or ALT, or abnormal physical examination findings
(such as bruising, distention, or tenderness), may indicate
the need for further abdominal imaging looking for
occult injury.15
In summary, it appears that laboratory panels in the
evaluation of children at risk for intra-abdominal injuries
are best utilized in conjunction with physical examination
findings and as a screen to determine those children who
might require further diagnostic testing, particularly
imaging.
Computed Tomography
Computed tomography (CT) with intravenous contrast
(IV) is the preferred modality for the diagnosis
A B
FIGURE 16-2  ■  CT scans are highly accurate in demonstrating solid organ injuries. (A) Hemoperitoneum with a liver laceration (arrow)
and a shattered spleen is seen. (B) Hemoperitoneum and a left renal laceration (arrow) is shown.
16  Abdominal and Renal Trauma 201
FIGURE 16-1  ■  Important physical findings
that might suggest intra-abdominal inju-
ries include the (A) ‘seat belt sign’ and the
(B) ‘handlebar mark.’ With patients exhib-
iting the seat belt sign, there is also poten-
tial for a spine fracture. The handlebar
mark may herald an underlying duodenal
hematoma or pancreatic injury.
of intra-abdominal injuries in hemodynamically stable
children.4 Newer generation scanners have excellent sen-
sitivity and specificity, especially for the evaluation of
solid organ injuries. Upwards of 95% of liver, spleen, and
renal injuries can be diagnosed and staged by CT (Fig.
16-2). Injuries to the intestine and pancreas are more
difficult to definitively diagnose by CT. However, with
the addition of coronal reconstructions, CT provides sig-
nificant information to guide the clinician regarding
these injuries. Similarly, the risk of a ‘missed’ intra-
abdominal injury in a child with a completely negative
CT is very low, leading some to advocate using CT as a
means to decrease the need for in-patient observation
after blunt abdominal trauma.16
It has been suggested that in young children who lack
visceral fat, the addition of oral contrast to the standard
IV contrast may be helpful, especially in evaluating the
duodenum and pancreatic head.17 The use of oral con-
trast, however, remains controversial due to concerns
regarding aspiration, and may not provide significant
additional information with current, multi-detector CT
imaging. Intravenous contrast, however, is essential for
the evaluation of traumatic injuries. If IV contrast is con-
traindicated, alternative methods of abdominal evalua-
tion should be considered.
202 SECTION II  Trauma
The radiation exposure during CT imaging has
become an area of major concern in children. The use of
CT has been rapidly increasing over the past decade, with
over seven million scans performed on children, mostly
for the evaluation of trauma and appendicitis.18 Using
models extrapolated from radiation exposure from the
atomic bomb explosions, a risk of one fatal cancer per
1000 CT scans performed in young children (above the
baseline cancer risk of approximately one in four adults
in the USA) has been estimated.19 A recently published
longitudinal, population-based study in Great Britain
demonstrated an increased incidence of leukemia and
brain cancer after repeated CT scans in children.20 Infants
and children are more sensitive than adults to the effects
of radiation given their small size (larger absorbed dose
per unit area) and growing organs.21 In response, the
pediatric radiology community has developed an Image
Gently® campaign to address the public’s concerns.21 In
addition, two recent position papers, authored by the
APSA Education Committee and the American Academy
of Pediatrics (AAP) Radiology Committee, have addressed
the issue of CT scans in children.22,23 Both endorse the
ALARA principle (as low as reasonably achievable) and
advocate for the use of scanners with pediatric dose
reduction software, employing alternative imaging
modalities (if available), limiting the number or phases of
scans (for example with and without contrast or arterial
and venous phases), and the use of limited scans. Other
concepts include limiting the number of repeat scans and
developing relationships with referring adult institutions
to limit the number of scans performed on children prior
to transfer.
Ultrasound
As concerns regarding CT have increased, there has been
a renewed interest in the use of ultrasound (US) in the
evaluation of pediatric abdominal trauma. The original
descriptions about ultrasound in trauma centered on the
rapid evaluation of the unstable adult trauma patient to
determine the presence and source of life-threatening
hemorrhage. The FAST (focused assessment with sonog-
raphy in trauma) examination was developed to assess the
presence of intra-abdominal free fluid (with examination
of Morrison’s pouch, the pouch of Douglas, and the left
flank) or fluid within the pericardial sac (subxiphoid
view), and thus indicate the need for operative explora-
tion. In multiple studies, the traditional FAST examina-
tion has been found to have a low sensitivity and specificity
for the diagnosis of injury in children.24–27 A recently
published large series directly comparing FAST examina-
tion in children to CT or laparotomy for the presence of
free fluid concluded that a positive FAST suggested
hemoperitoneum and associated abdominal injury, but a
negative FAST adds little in decision making.28 In addi-
tion, since the majority of pediatric solid organ injuries,
even those with significant free fluid (hemoperitoneum),
can be managed nonoperatively, a positive FAST exami-
nation may not be very helpful in directing clinical care.
On the other hand, the use of provider-performed ultra-
sound has increased dramatically over the past several
years in the pediatric ED, and there is significant interest
in developing algorithms that incorporate ultrasound
into the evaluation of abdominal trauma.29,30 The ulti-
mate goal is to limit the number of CT scans. In the less
common scenario of the hemodynamically unstable child,
a positive FAST examination supports the decision to
rapidly proceed to the operating room.
Laparoscopy
Minimally invasive approaches are now well incorporated
in pediatric surgical practice so it is not surprising that
laparoscopy for the evaluation of abdominal trauma is
being utilized. Despite the excellent anatomic definition
provided by multi-detector CT, there remain areas of
diagnostic uncertainty. The child with free fluid without
evidence of solid organ injury, particularly with physical
examination findings of a seat belt or handlebar mark, is
one example. Another scenario is the child with signifi-
cant abdominal tenderness with a nondiagnostic CT
scan. If the findings at laparoscopy indicate the need for
a formal laparotomy, an open approach can be targeted
to the specific injury. In two relatively large reviews,
laparoscopy was found to be safe and beneficial by avoid-
ing laparotomy in a significant number of patients.31,32
Also, a number of injuries were amenable to laparoscopic
repair. CT and laparoscopy now provide complementary
information, with CT defining areas, such as the retro-
peritoneum, kidneys, and pancreas, which are difficult to
assess using laparoscopy. On the other hand, laparoscopy
allows for direct visualization of the bowel, mesentery,
and diaphragmatic surfaces, regions that CT has tradi-
tionally not been as accurate (Fig. 16-3).
MANAGEMENT
Liver and Spleen
Close to 90–95% of injuries to the liver and spleen in
children can be managed nonoperatively. It is rare for
isolated low grade injuries to these organs to require
blood transfusion.33 Nonoperative management (NOM)
is dependent upon the accurate diagnosis and staging of
the injured organ, usually by CT imaging at present.
Injuries are graded according to the American Associa-
tion for the Surgery of Trauma (AAST) organ injury
scale, with grade I injuries representing small lacerations
or hematomas and grade V injuries indicating complete
vascular disruption or massive parenchymal injury (Table
16-1).34 In order to be a candidate for NOM, the child
should have normal hemodynamics, and be monitored
closely for signs of ongoing hemorrhage. Most children
who fail NOM do so within four hours of injury as a
result of shock, peritonitis, or persistent bleeding.35 Late
failures are often the result of peritonitis due to an evolv-
ing intestinal injury. There are published, evidence-based
guidelines for NOM in a child with a liver or spleen
injury.36,37 Essentially, these guidelines recommend hos-
pitalization for ‘grade of injury plus one’ days, and note
that children with higher grade injuries may benefit from
intensive care unit observation. Routine follow-up
imaging is not indicated, and children can return to
 16  Abdominal and Renal Trauma 203

A B

FIGURE 16-3  ■  In some patients it is not always clear whether a significant intestinal injury has occurred from either blunt or penetrat-
ing trauma. Diagnostic laparoscopy is a useful technique in these patients. (A) Perforation of the bowel from penetrating trauma is
seen at laparoscopy. This was closed primarily. (B) Full-thickness injury to the colon (arrow) in a patient with blunt trauma is shown.
The laparoscopic approach was converted to an open operation for treatment of this injury.

regular activity after grade of injury plus two weeks from
the time of injury. More recent work challenges these
recommendations, finding that more abbreviated periods
of bed rest and hospitalization does not result in delayed
bleeding or return to the hospital.38 Fortunately, most
splenic and hepatic injuries in children will resolve
without the need for operative intervention with excel-
lent long-term outcomes.
While bleeding from most solid organ injuries in chil-
dren will stop, there are a small number in which the
bleeding is significant. Tachycardia, not responsive to
fluid resuscitation, is the initial sign of shock in these
children. Hypotension is often a late finding and suggests
significant hemorrhage. Evidence of ongoing bleeding
with an abnormal abdominal examination or a positive
abdominal FAST examination necessitates urgent opera-
tive exploration. Rapid transfusion protocols, while not
formally validated in children, are utilized with the goal
of 1 : 1 : 1 transfusion of packed red blood cells (PRBC),
fresh frozen plasma (FFP), and platelets. In infants and
children, this translates to 20 mL/kg of PRBC, FFP and
platelets.39 In the operating room, a rapid transfusion
device and cell saver should be available in the event of
rapid blood loss. The patient is prepped from neck to
knees to allow for entrance into either the chest or
abdomen, and to have access to the femoral vessels. Upon
entrance to the abdomen, the four quadrants are packed
to tamponade the bleeding and allow the anesthesiolo-
gists to ‘catch-up.’ The peritoneal contents are then
explored in a systematic fashion. The goal of initial oper-
ative exploration is to stop bleeding and control the fecal
stream (damage control).
Splenectomy easily controls bleeding in the hemody-
namically unstable patient with active exsanguination
from a massively damaged spleen, although at the theo-
retical cost of a long-term risk of postsplenectomy sepsis.
Children with splenic injuries who have ongoing bleed-
ing, but are not in shock, are potential candidates for
splenic sparing operations. Partial splenectomy and mesh
splenorrhaphy are techniques that can successfully save
splenic parenchyma, although they may be time consum-
ing, and are therefore not appropriate in the unstable
patient.40
Postsplenectomy sepsis is a rare, but potentially fatal
consequence of splenectomy due to overwhelming
infection by encapsulated organisms. The reported
incidence is around 0.23% a year, with an increased
incidence in children less than 2 years of age, and those
that underwent splenectomy for hematologic reasons.41
Vaccination with the 23-valent pneumococcal vaccine, as

TABLE 16-1 Liver/Spleen Injury Grading Scale from the AAST

Grade Injury Description of Injury
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm parenchymal depth
II Hematoma Subcapsular, 10–50% surface area
Intraparenchymal, <10 cm in diameter
Laceration Capsular tear, 1–3 cm parenchymal depth, <10 cm length
III Hematoma Subcapsular, >50% surface area or expanding
Ruptured subcapsular or parenchymal hematoma
Intraparenchymal hematoma >10 cm or expanding
Laceration >3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25–75% of hepatic lobe or 1–3 Couinaud’s segments within a single
lobe
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3

Vascular Juxtahepatic venous injuries: i.e., retrohepatic vena cava/central major hepatic veins
Vascular Couinaud’s segments within single lobe
Hepatic avulsion

From Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver,
and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008;207:646–55.
204 SECTION II  Trauma
well as vaccinations against Haemophilus influenzae type B
and meningococcus, should be administered after
splenectomy. With high grade splenic injuries managed
nonoperatively, assessment of splenic function may also
be indicated.
A major hepatic injury is considerably more difficult
to control in the operating room. The segmental anatomy
of the liver and the location of important arterial, venous,
and portal structures is very important. Peitzman and
Marsh recently reviewed operative techniques for the
management of complex liver injury.42 Key components
of operative control of hepatic parenchymal injury include
adequate exposure, an experienced co-surgeon, good
anesthesia support, and supradiaphragmatic intravenous
access. They recommend initial management of deep
parenchymal fractures with compression, followed by
suture ligation of bleeding vessels, and the avoidance of
deep liver sutures. The Pringle maneuver can help dif-
ferentiate between hepatic arterial bleeding (decreases
when the clamp is engaged) and hepatic venous bleeding.
Ideally, intermittent clamping of the porta hepatis should
be performed to decrease the degree of hepatic ischemia.
Large fractures are best treated with anatomic or non-
anatomic resection, assuming enough residual liver
remains. Resection can be efficiently performed using
mechanical staplers. While the definitive operation must
control bleeding and bile leak, debride nonviable tissue,
and adequately drain the resected margin, control of
hemorrhage is the primary concern in an emergency
operation. Temporizing maneuvers, such as packing with
control of bleeding, are performed and a temporary
abdominal closure is created to allow for ongoing resus-
citation and to prevent abdominal compartment syn-
drome. Vacuum dressings have been developed specifically
for this purpose, but techniques such as the ‘Bogota bag’
are still viable alternatives. Multiple trips to the operating
room for wash-out, packing removal, and treatment of
other injuries may be required before the patient is ready
for formal abdominal closure.
Abdominal Compartment Syndrome
Abdominal compartment syndrome (ACS) is defined as
sustained intra-abdominal hypertension (IAH) that is
associated with new onset organ dysfunction or failure.43,44
It is an uncommon, but potentially lethal condition that
occurs when abdominal distension associated with IAH
A B
FIGURE 16-4  ■  (A) Abdominal wall expansion was performed in this patient with a bowel bag. (B) Abdominal wall expansion in this
patient was accomplished with a polytetrafluoroethylene patch.
causes reduced perfusion to the intra-abdominal organs.
The result is ischemia and refractory metabolic acidosis
along with interference with cardiopulmonary function
secondary to reduced preload from decreased central
venous return to the heart, decreased respiratory compli-
ance, and decreased functional residual capacity.45 ACS is
associated with a 40–60% mortality in children.46–48
As IAH in children is different from adults, the current
proposed working definition for ACS in children is an
elevated intra-abdominal pressure (IAP) of 10 mmHg or
greater with the development of new or worsening mul-
tiorgan failure.44 There are three different types of ACS:
(1) primary ACS refers to ACS that occurs due to a
primary intra-abdominal cause such as abdominal trauma;
(2) secondary ACS or extra-abdominal compartment syn-
drome occurs as a result of massive bowel edema second-
ary to sepsis, capillary leak, and other conditions requiring
massive fluid resuscitation; and (3) tertiary ACS or recur-
rent ACS in which ACS recurs after resolution of an
earlier episode of either primary or secondary ACS.49 IAP
can be measured by using the bladder pressure. If IAH is
detected, serial IAP measurements are needed. It is
important to note that clinical examination is an inac-
curate predictor of IAP and should not be substituted for
IAP measurement.50
Initial management strategies in the trauma patient
include improving abdominal wall compliance via ade-
quate sedation and paralysis, evacuation of intralumenal
intestinal contents, evacuation of large abdominal fluid
collections, optimization of fluid administration by goal-
directed therapies and correcting positive fluid balance,
and optimization of abdominal perfusion pressure.51 Over
the last ten years, three major changes have led to signifi-
cant reductions in the incidence and mortality from ACS
in adult trauma patients. These are adoption of massive
transfusion protocols and 1 : 1 blood to plasma transfu-
sion strategies in trauma, the widespread use of damage
control and open abdomen approaches to the polytrau-
matized abdominal cavity, and an increased use of plasma
and colloids in the resuscitation of burn patients.51 Similar
strategies and an increased awareness of ACS in pediatric
trauma patients may also result in improved outcomes.
In the unstable trauma patient who requires an emer-
gent laparotomy and massive fluid resuscitation, main-
taining an open abdomen with planned staged closure
may prevent the development of ACS but often needs to
be performed prophylactically (Fig. 16-4A). In patients

who develop ACS, early intervention via emergent
decompressive laparotomy and some form of temporary
abdominal wall closure, while awaiting resolution of
IAH, can be lifesaving (Fig. 16-4B).46,48,52 The goals of
operation are to decrease the elevated IAP to stop organ
dysfunction, allow room for continued expansion of the
viscera during ongoing resuscitation, provide temporary
abdominal closure, prevent excessive fascial retraction,
and allow a means for continued evacuation of fluid from
the abdominal cavity.51 Application of a negative pressure
wound dressing to the open abdomen is a useful tempo-
rary dressing as well as a modality to remove edema from
the abdominal cavity and intestinal wall.53 Temporary
patch abdominoplasty with a variety of materials and the
placement of a silo have also been utilized in the setting
of an open abdomen. However, these methods lack the
capability to actively evacuate excess fluid. Subsequent
staged abdominal closure with sutures or patch abdomi-
noplasty is performed when IAH is corrected.
Role of Interventional Radiology
Angioembolization is a technique that is frequently uti-
lized in adults with splenic or hepatic vascular injuries.
The role of interventional radiology in children is less
well defined. For example, embolization in adults is fre-
quently employed for the management of a contrast blush
demonstrated on CT scan. Multiple studies in children,
however, demonstrate that a contrast blush is associated
with the need for operative intervention in less than 20%
of splenic injuries.54–56 Long-term follow-up of large
cohorts of children with splenic and hepatic injuries also
reveal a very low rate of late bleeding, suggesting that the
rate of bleeding from an initially unrecognized arterial
pseudoaneurysm is also very low.36,37 On the other hand,
small single-center studies and case reports demonstrate
that interventional radiological techniques are safe in
children, and have been effective when utilized.57–60 The
population that seems most amenable to this technique
are children with evidence of ongoing bleeding but are
hemodynamically stable, or those that develop bleeding
later in their hospital course. In our institution, we have
effectively utilized angioembolization in a few cases of
hepatic arterial bleeding (Fig. 16-5).
Special Considerations with
Liver Injuries
The initial concern with hepatic injury is control of
bleeding, but injury to the biliary system can also occur.
High grade liver injuries are associated with a small (4%)
risk of a significant bile leak.61 If the patient has required
operative management for the injury, it is prudent to
place closed suction drains around the liver, particularly
if a nonanatomic resection was performed. With nonop-
erative management, the development of a significant
bile leak is often heralded by feeding intolerance, abdom-
inal pain, elevations in hepatic enzymes, and fever.62
Abdominal imaging (either ultrasound or CT) reveals the
presence of a fluid collection. Initial management involves
the insertion of drains, usually performed percutaneously
with image guidance.
16  Abdominal and Renal Trauma 205
FIGURE 16-5  ■  This hepatic artery angiogram was performed in
a patient with persistent hemorrhage after initial damage-
control laparotomy. The site of hemorrhage is identified (arrow),
and embolization was successfully performed.
Endoscopic retrograde cholangiopancreatography
(ERCP) has been used to identify the location of the leak,
and more importantly, with the addition of sphincterot-
omy, to decrease biliary pressure and promote internal
drainage.63,64 Placement of biliary stents can also be per-
formed, both to improve drainage and to treat the ductal
injury. Therapeutic ERCP requires operator expertise,
and heavy sedation or general anesthesia for the proce-
dure to be safely performed in children. In the case of
stent placement, a second endoscopic procedure to
remove the stent is usually necessary. Complications of
ERCP include bleeding, sepsis, and stent migration or
clogging.
Pancreatic Injuries
Injury to the pancreas occurs in fewer than 5% of pedi-
atric abdominal injuries, and can be difficult to diagnose.
They are most frequently the result of blunt mechanisms,
such as MVC and bicycle handlebar injuries. Patients
usually present with significant epigastric pain and bilious
emesis, particularly in the case of injuries that have a
delayed presentation. CT scan with IV contrast is the
preferred imaging study, although definitive identifica-
tion of these injuries can be difficult (Fig. 16-6). In
unusual cases, magnetic retrograde cholangiopancreatog-
raphy (MRCP) can be helpful. ERCP, if available, may
be helpful in determining whether there is a major ductal
injury, and may have a potential therapeutic role, but is
an invasive and a technically challenging procedure.65
Contusions, without evidence of pancreatic ductal
injury, can be managed nonoperatively with nothing by
mouth. The child is followed symptomatically as an oral
diet is reintroduced. Trends in serum amylase and lipase
may be helpful, although the absolute value of these tests
does not correlate with outcome.66 Management of ductal
transection is currently controversial. The standard
approach for a distal ductal transaction is a spleen
206 SECTION II  Trauma
FIGURE 16-6  ■  This abdominal CT scan demonstrates blunt
transection of the pancreas (arrow).
FIGURE 16-7  ■  This patient presented with a pancreatic transec-
tion just lateral to the vertebral column. He underwent  Hollow Viscus Injury
laparoscopic exploration followed by a laparoscopic distal pan-
createctomy with preservation of the spleen. The remaining
pancreas is noted with the asterisk and the staple line is marked
with the arrow.
preserving distal pancreatectomy. This procedure, which
can be performed via an open laparotomy or laparoscopi-
cally (Fig. 16-7),67,68 is generally well tolerated, and pre-
vents pseudocyst formation. Concerns regarding late
morbidity, particularly endocrine insufficiency, have led
to other treatment approaches. One group has advocated
for the use of Roux-en-Y distal pancreaticojejunostomy
using a retrocolic jejunal limb to drain the distal pan-
creas.69 Others have advocated a nonoperative approach
to pancreatic ductal injuries, with percutaneous or endo-
scopic drainage of subsequent pseudocysts.70,71 A recent
APSA Trauma Committee retrospective review com-
pared operative and nonoperative management, and
demonstrated similar length of hospitalization, but a
higher rate of pseudocyst formation and days on total
parenteral nutritional (TPN) in the nonoperative group.72
Patients undergoing NOM often require ERCP to define
the ductal anatomy, perform sphincterotomy, and poten-
tially stent the pancreatic duct, as well as percutaneous
or endoscopic drainage of pseudocysts. At this time, it is
unclear which patient population will benefit from a non-
operative approach for a pancreatic ductal injury. In addi-
tion, the nonoperative approach requires the availability
of advanced endoscopic techniques and ERCP.
Diaphragmatic Injury
Blunt traumatic rupture of the diaphragm via massive
compressive forces to the abdomen accounts for 80–90%
of diaphragmatic injury in the pediatric population.73
This injury rarely occurs in isolation, but is often associ-
ated with multiple organ injury and a high index of sever-
ity scores.74 Abdominal contents may herniate into the
thoracic cavity due to the pressure gradient between the
pleura and peritoneal cavities. Right and left sided rup-
tures occur with equal frequency.75 Plain radiographs may
suggest the diagnosis of traumatic diaphragm rupture via
an obscured or elevated hemidiaphragm, gas in herniated
viscus above the diaphragm (Fig. 16-8A), tip of nasogas-
tric tube in the thorax, the presence of an atypical pneu-
mothorax, and plate-like atelectasis adjacent to the
diaphragm.73
Emergent operative exploration in patients with dia-
phragm injury is indicated in the hemodynamically
unstable patient with multiple organ injury. A thorough
and systematic exploration of the entire abdomen and
palpation of retroperitoneal structures is required due to
the frequency of multiple organ injury. Repair of the
diaphragmatic defect is typically possible after debride-
ment of any compromised tissue. If large defects are
found, a prosthetic patch may be needed to minimize the
tension. Successful laparoscopic or thoracoscopic repair
of diaphragmatic injuries can be performed in hemody-
namically stable children and in cases with delayed diag-
nosis (Fig. 16-8B, C).76–78
Hollow viscus injury in children is typically caused by
blunt trauma via crush injury from a focal or localized
blow to the abdomen such as a bicycle handle bar, a
punch to the abdomen, or from a seatbelt in an MVC.
Distended hollow viscera are more prone to rupture with
blunt trauma due to the increased intraluminal pressure.79
Areas of mesenteric fixation such as the proximal jejunum
near the ligament of Trietz, the distal ileum near the
ileocecal valve, and the rectosigmoid junction are par-
ticularly vulnerable to injury via acceleration/deceleration
shearing forces. Seat belt signs may also be markers of
severe deceleration injury to the abdomen with an associ-
ated intra-abdominal blunt hollow viscus injury.80 In this
injury complex, the rapid deceleration from a high impact
crash causes sudden flexion of the upper body around the
fixed lap belt and consequent compression of the abdomi-
nal viscera between the lap belt and the spine. This injury
is accentuated by using adult seat belts without booster
seats in young children or using lap belts without shoul-
der straps. The use of age-appropriate child restraints in
cars may prevent some of these injuries.81
Children with traumatic hollow viscus injury and per-
foration typically present with signs of peritoneal irrita-
tion due to the rapid contamination of the peritoneal

A B
FIGURE 16-8  ■  This teenager developed respiratory symptoms several weeks after a motor vehicle accident. (A) The chest radiograph
shows air in either the stomach or the intestine in the left chest. (B) At laparoscopic exploration, the traumatic diaphragmatic hernia
is seen after reduction of the stomach and several loops of small intestine. (C) The traumatic diaphragmatic hernia was repaired
laparoscopically and the patient recovered uneventfully.
cavity. In a neurologically intact patient with a perforated
viscus, findings of abdominal tenderness, guarding, and
rebound on initial and serial physical examinations are
more specific for hollow viscus injury than abdominal
ultrasound or CT findings for these injuries.82–84 Hemo-
dynamically unstable patients with signs and symptoms
of hollow viscus injury should undergo an emergent
exploratory laparotomy. In stable patients, more time can
be taken for evaluation and a CT scan of the abdomen
and pelvis can be performed. CT findings suggestive of
hollow viscus injury include bowel wall thickening and
enhancement, mesenteric stranding, and free intraperito-
neal fluid in the absence of solid organ injury.12 Despite
currently available diagnostic studies, partial thickness
lacerations, hematomas, or avulsions of mesenteric vessels
may not initially appear significant, but can progress to
full-thickness intestinal wall ischemia and perforation
with leakage of intestinal content over hours to days.
Some mesenteric injuries may result in an intestinal stric-
ture or internal hernia diagnosed weeks after the acci-
dent. A recent multi-institutional retrospective review by
the APSA Trauma Committee determined that delay in
operative treatment up to 24 hours did not significantly
affect outcome.85
In hemodynamically stable patients with evidence of
bowel injury or in equivocal cases with concerning physi-
cal signs or symptoms, diagnostic laparoscopy is a very
reasonable approach. In cases with penetrating trauma,
local wound exploration to identify penetration of the
anterior abdominal fascia is recommended as the initial
diagnostic maneuver. If it is still unclear whether the
peritoneum has been violated, then laparoscopy can be
performed to determine whether there is penetration
into the abdominal cavity and also to assist with the crea-
tion of a diverting stoma, if needed.32,86,87 Whether explo-
ration is performed laparoscopically or via an open
approach, a four quadrant inspection of the abdominal
cavity with meticulous examination of both the intestinal
tract and mesentery should be performed. The lesser sac
should be opened to evaluate the posterior gastric wall,
the pancreas, and diaphragm. Regardless of the approach,
principles of management of hollow viscus injury include
prompt resuscitation, complete removal of devitalized
tissue, reconstruction or diversion of the intestinal tract,
and perioperative antibiotic coverage.
16  Abdominal and Renal Trauma 207
C
Injury to the Stomach
Penetrating injury to the stomach is more common than
blunt trauma, and results in a variable presentation of
local tissue destruction. Despite its rarity, blunt injury
to the stomach can occur and is typically seen in the
patient who has just eaten, as the full stomach is more
vulnerable to burst injury.88,89 When gastric rupture
occurs, it is usually located along the greater curvature
with a blow-out or stellate configuration. At exploration,
the posterior wall of the stomach and the gastroesopha-
geal junction should always be evaluated to avoid missed
injuries.89 Debridement with repair of the injury is
sufficient.
Duodenal Injuries
The majority of duodenal injuries in children result from
blunt mechanisms.90,91 In younger patients, duodenal
injury is often the result of nonaccidental trauma and
isolated injury should raise suspicion if the history or
mechanism is inconsistent with the injury.9,92 Due to its
contiguous location to many other vital structures, asso-
ciated injuries are common. Also, because of its location
close to the vertebral column, blow-out injuries can
occur.93 Diagnosis of a duodenal injury may be difficult
due to the retroperitoneal nature of the duodenum, the
poor sensitivity of plain radiographs, and the nonspecific
nature of examination findings in these patients. Abdomi-
nal CT is the test of choice to evaluate for duodenal
injury. Injuries to the duodenum as graded by the AAST
range from hematomas involving only a portion of the
duodenum (grade I) to devascularization of the duode-
num or massive disruption of the duodenopancreatic
complex (grade V) (Table 16-2).94
Duodenal hematomas may be found on CT or upper
GI studies revealing transmural thickening with lumenal
duodenal narrowing, or partial obstruction without evi-
dence of extravasation of air or contrast (Fig. 16-9). They
are typically managed nonoperatively with nasogastric
decompression and TPN over one to three weeks.95
Operative evacuation of the hematoma may be required
if obstructive signs and symptoms do not resolve. Evacu-
ation of the hematoma may also be performed if the
duodenal hematoma is found on laparotomy or
208 SECTION II  Trauma

TABLE 16-2 Duodenal Injury Grading Scale

from the AAST
Grade Injury Description of Injury
I Hematoma Involving single portion of wall
Laceration Partial thickness, no perforation
II Hematoma Involving more than one portion
Laceration <50% circumference disruption
III Laceration Disruption 50%–75% circumference
of 2nd portion
Disruption 50%–100%
circumference of 1st, 3rd, or 4th
portions
IV Laceration Disruption of >75% circumference
of 2nd portion
Involvement of ampulla or distal
common bile duct
V Laceration Massive disruption of
duodenopancreatic complex
Duodenal devascularization

From Moore EE, Cogbill TH, Malangoni MA, et al. Organ

injury scaling, II: Pancreas, duodenum, small bowel, colon, A
and rectum. J Trauma 1990;30:1427–9.

laparoscopy for other injuries. CT scan findings of

extravasation of air or contrast into the paraduodenal,
pararenal, or retroperitoneal space is consistent with duo-
denal perforation.95 Early diagnosis can simplify manage-
ment and minimize morbidity, but delay in diagnosis is
not uncommon due to a delay in presentation or the
paucity of findings on initial imaging.96–98 When high
clinical suspicion for duodenal injury exists and initial
radiographs and abdominal CT scans do not reveal
significant injury, serial CT scans may be indicated to
look for the delayed development of retroperitoneal
air. Delay in diagnosis of greater than 24 hours is associ-
ated with established peritoneal inflammation, poor
tissue integrity, and a higher leak rate following primary
repair.91
Complications, such as fistula formation, are more
common (2–14%) after repair of duodenal injuries than
following operative repair for any other area of the gas-
trointestinal tract.91 Several operative techniques such as
serosal patch repair, transverse primary repair, duodenal
diverticularization, pyloric exclusion, and gastrojejunos-
tomy have been applied to duodenal injuries to minimize
potentially significant complications.93,95,98 Operative
intervention for duodenal injuries should be made based
on clinical judgment. Most full-thickness injuries with
minimal tissue destruction not involving the drainage of
the biliary or pancreatic ductal system can be repaired
primarily.99 In patients with a complex duodenal injury,
diversion and drainage may be needed (Fig. 16-10). In
these cases, a duodenostomy tube and gastrostomy may
be helpful for decompression. A feeding jejunostomy is
recommended for early enteral nutrition, and drains
should be placed near the repair. Earlier diagnosis of
duodenal injuries may make the injury more amenable to
primary repair while a significant delay in diagnosis (>24
hours), or those with a grade III or greater injury, may
warrant proximal drainage via a gastrojejunostomy and
pyloric exclusion.91,100
B
FIGURE 16-9  ■  This patient developed emesis soon after a bicycle
accident. The upper gastrointestinal contrast study (A) shows a
very narrowed duodenum due to extrinsic compression from a
large mass in either the pancreas or wall of the duodenum. The
CT scan (B) in the same patient shows a very small rim of con-
trast material (arrow) and a very large intramural duodenal
hematoma (asterisk).
Injury to the Small Intestine and Colon
Injuries to the small intestine range from transmural
hematomas, simple lacerations, complete transection, or
mesenteric avulsions with segments of compromised
bowel (Fig. 16-11). Even in cases of massive contamina-
tion, simple repair, debridement, or resection with
primary anastomosis is usually appropriate.
Injury to the colon is infrequent but more often sec-
ondary to penetrating mechanisms than blunt injuries in
pediatric patients.101 The infrequent nature of colonic
injuries in children hinders the development of guide-
lines, and the management principles are extracted from
the adult trauma experience. Historically, concerns over
peritoneal contamination with colonic injury encouraged
diversion to avoid anastomotic leaks and ongoing sepsis.
Currently, primary repair of early diagnosed colonic

FIGURE 16-10  ■  This patient was suspected of having a duodenal
injury after a CT scan showed upper abdominal fluid and retro-
peritoneal air adjacent to the duodenum. At operation, this
patient was found to have a complete duodenal transection fol-
lowing a handlebar injury. As the two segments of duodenum
appeared viable (arrows), a primary repair was performed. The
patient recovered uneventfully.
FIGURE 16-11  ■  The small bowel mesentery has been avulsed,
resulting in ischemic bowel.
injuries can be performed safely and is the preferred
approach, even if there is peritoneal contamination.101,102
A Cochrane meta-analysis evaluating adult patients with
colonic trauma summarizes outcomes with primary repair
vs. diversion.102 This analysis significantly favored primary
repair as the optimal treatment due to the reduction in
morbidity and a decrease in procedure-related costs. In
the setting of significant devitalizing colonic injury in a
patient in shock, initial damage-control laparotomy is
recommended with delayed colonic anastomosis at the
time of abdominal wall closure. In this scenario, a higher
complication rate has been found with delayed
16  Abdominal and Renal Trauma 209
anastomosis if fascial closure occurs greater than 5 days
after injury and in the case of a left colonic injury.103 A
diverting colostomy rather than a delayed anastomosis
should be performed at the time of abdominal wall
closure in patients with recurrent intra-abdominal
abscesses, severe bowel wall edema and inflammation, or
persistent metabolic acidosis.104 A diverting colostomy
may also be needed in patients with simultaneous exten-
sive abdominal wall or perineal injury.
Injury to the Rectum
Pediatric anorectal injury is uncommon, but may occur
through a variety of mechanisms, especially falls with
straddle injuries, and sexual abuse.105 Accidental falls
often cause injury to the perineal body, external genitalia,
urethra and anus, but rectal injury is uncommon (Fig.
16-12). Impalement on fixed objects occurs, but is typi-
cally an isolated injury. Sexual abuse often causes isolated
rectal or vaginal trauma, and should be considered as a
possible etiology in patients with isolated perineal inju-
ries.105 Blunt rectal injury secondary to MVC is often
associated with multiple injuries, such as pelvic fractures
and urinary tract injuries.106 Another notable mechanism
in children occurs from the use of personal watercraft (jet
skis, seadoos, and wave-runners).107–109 Passengers thrown
from personal watercraft can experience significant
hydrostatic force of water through the anal canal on
landing, resulting in rectal injury and perforation. These
hydrostatic rectal perforations, although rare, are occur-
ring with increasing frequency, and are potentially dev-
astating. In the USA, the National Transportation Safety
Board has recommended wet suit bottoms for all children
on personal watercraft as operators or passengers.109
In the evaluation of rectal injury, digital rectal exami-
nation is unreliable.110 In the stable patient, abdominal
and pelvic CT scans can be helpful.111 Diagnosis of the
extent of injury often requires examination under anesthe-
sia at which time, vaginoscopy, anoscopy, proctoscopy,
and possible cystoscopy are performed as necessary.112
FIGURE 16-12  ■  This teenager developed this full-thickness strad-
dle rectal injury after falling off a trampoline. It was possible to
close the injury over drains placed in the perirectal tissues. He
has recovered uneventfully with full continence.
210 SECTION II  Trauma
Laparoscopy may be needed to evaluate for intra-
peritoneal extension.106 Most vaginal, anal, and superficial
perineal body injuries can be treated with primary repair.
Historically, rectal trauma was managed with a diverting
colostomy, drainage of the perineal wound, and rectal
irrigation.113 Currently, selective diversion has been advo-
cated for both pediatric and adult patients with good
results.7,106
Gallbladder Injury
The gallbladder is rarely injured in children. However,
associated injuries are common.114,115 Predisposing factors
for gallbladder trauma are a thin-walled normal gallblad-
der, a distended gallbladder after a meal, and alcohol
ingestion. If identified, a cholecystectomy is usually per-
formed. This may be performed via laparoscopy or
laparotomy.
Urinary Bladder
The bladder is the second most common genitourinary
(GU) injury in children.116,117 Bladder injuries range from
grade I contusions to grade V extraperitoneal or intra-
peritoneal ruptures involving the bladder neck or ureteral
orifices.118 It is hypothesized that the bladder’s rostral
location in relation to the pelvis increases the risk of
injury in children.119 CT cystography is used to evaluate
a suspected bladder injury. Prompt repair is required for
intraperitoneal ruptures as incomplete drainage of intra-
abdominal urine can lead to infection, peritonitis, and
even death.120 Typically, a two layered closure with
absorbable suture material is performed, and either
transurethral or suprapubic drains are used for temporary
decompression. Urethral catheter drainage is considered
sufficient for uncomplicated extraperitoneal ruptures.120
Renal Trauma
With abdominal trauma in children, the kidney is injured
in approximately 10% of patients, and is the most com-
monly injured GU organ.121 The susceptibility of chil-
dren for major renal trauma compared to adults appears
in part secondary to the fact that the kidney occupies a
relatively larger amount of the retroperitoneal space, the
thoracic cage is less well ossified, the abdominal muscu-
lature is weaker, and there is less cushioning from
perirenal fat.122 Congenital renal anomalies such as
hydronephrosis, tumors, or abnormal positions have
been postulated to make the kidney more susceptible to
trauma with relatively mild traumatic forces. However,
recent studies do not support this concept.116 Congenital
abnormalities are present in approximately 1–5% of renal
injuries.
Blunt trauma accounts for 80–90% of renal injuries in
children. The most common mechanisms are related to
MVC, falls, bicycle, and all-terrain vehicle (ATV)-related
injuries.123 In several series, the most severe grade of
injury was related to dirt bikes, ATV rollovers, and bicy-
cles.119,123 Most children who sustain renal injury in an
MVC are unrestrained.124 ATV-related injuries suggest
a unique injury mechanism such as a strike from the
handlebars, collisions involving ejection, or ATV rollo-
ver. Increased awareness and use of proper safety equip-
ment may contribute to decreased prevalence and severity,
including abdominal or flank padding, to reduce blunt
force and handlebar intrusion.119
Patients with renal trauma typically present with gross
hematuria and flank pain. The diagnosis is confirmed by
abdominal CT scan which is highly sensitive. Renal inju-
ries have also been classified by the AAST (Table 16-3).
This classification system has been useful in standardiz-
ing and validating treatment strategies.125 Management
goals involve maximizing functional renal parenchyma
while minimizing patient morbidity.126 Expectant
NOM is widely accepted for hemodynamically stable
grade I-III renal injuries which do not have urinary
extravasation.127
Treatment for children with high grade renal injury
(grade IV and grade V) remains controversial (Fig.
16-13). Urinary extravasation and urinoma continue to
be relative indications for exploration in some centers.128
Historically, patients with higher grade injury were also
more likely to undergo endourologic interventions such
as nephrostomies or ureteral stents.129,130 Most current
pediatric series report successful nonoperative manage-
ment for grade IV and V injuries.127 Endourologic inter-
ventions are reserved primarily for persistent extravasation
or symptomatic urinomas rather than all injuries with
disrupted collecting systems.127 Selective angioemboliza-
tion of renal artery branches has been successful in nearly
80% of cases with delayed hemorrhage.131 Using indi-
vidualized selective management, several studies have
documented renal preservation in over 95% of chil-
dren.127,132,133 The main indications for immediate explo-
ration in a child with a renal injury are hemodynamic
TABLE 16-3 Renal Injury Grading Scale
from the AAST
Grade Injury Description of Injury
I Contusion Microscopic or gross hematuria,
normal urologic studies
Hematoma Subcapsular, nonexpanding
without parenchymal laceration
II Hematoma Nonexpanding perirenal hematoma
confined to renal
retroperitoneum
Laceration <1.0 cm parenchymal depth of
renal cortex without urinary
extravasation
III Laceration >1.0 cm parenchymal depth of
renal cortex without collecting
system rupture or urinary
extravasation
IV Laceration Parenchymal laceration extending
through renal cortex, medulla
and collecting system
Vascular Main renal artery or vein injury
with contained hemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilum that
devascularized kidney
From Moore EE, Shackford SR, Pachter HL, et al. Organ injury
scaling: spleen, liver, and kidney. J Trauma 1989;29:1664–6.
 16  Abdominal and Renal Trauma 211

23,666 reported injuries in the study, only 18 involved a

kidney, and none were catastrophic or required opera-
tion. This number of renal injuries is far fewer than
injuries reported for other unpaired organs such as the
head, neck, spine, or brain. Cycling, downhill skiing, and
horseback riding (classically referred to as ‘limited contact
sports’) are recreational activities that were found to have
comparable or higher rates of renal injury in comparison
with American football, yet are often not restricted by
practitioners.140
Additionally, studies have shown that the risks of
kidney injury from nonathletic pursuits are far more
common than those from sport participation. MVCs
alone account for two to ten times more kidney injury
than sports.141 Likewise, ATV and motorcycle use has a
much greater risk of serious renal injury compared with
participation in contact sports.123

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FIGURE 16-13  ■  This child developed a grade III injury to the right
kidney. There is a deep laceration through the central aspect of
the kidney (arrow), but no evidence of urinary extravasation or
development of a urinoma. This patient was managed nonop-
eratively and recovered uneventfully.
instability, penetrating mechanism, and associated non-
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Stable patients with high grade injury are typically
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million high school ‘athlete exposures,’ discovered that
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