Abdominal solid organ and hollow viscus injury

• Abdominal trauma is divided into injury to the solid organs (liver, spleen, kidneys, pancreas) and to the hollow viscera and their mesentery (stomach, small bowel, colon, rectum, duodenum). Blunt and penetrating mechanisms produce different injury patterns and are managed differently.
• The patient is resuscitated and examined using the ATLS primary survey (airway, breathing, circulation, disability, exposure). A bedside ultrasound (FAST or eFAST) looks for free fluid, and a contrast CT of abdomen and pelvis grades injuries in stable patients.
• Haemodynamic status, not the grade on CT alone, decides whether non-operative management (NOM) is safe or whether the patient goes to theatre. NOM is now standard for most blunt solid-organ injuries in a monitored setting.
• Hollow-viscus and mesenteric injuries are missed more easily: peritoneal signs can take hours to develop, and initial CT misses about one in five bowel injuries. High-risk patients need observation, serial examination, and sometimes a repeat CT at about 6 h. ^[5]
• Penetrating wounds without peritonitis or haemodynamic instability may be managed selectively in experienced centres, with laparotomy reserved for instability, diffuse tenderness, peritonitis, or evisceration.

By the end of this page you should be able to:

1. Explain how blunt and penetrating mechanisms produce different abdominal injuries, and use the anatomy of each organ to explain its presentation.
2. Apply the ATLS primary survey and FAST (eFAST) to a trauma patient, and interpret a contrast CT in planning management.
3. State the AAST 2018 grades for liver, spleen and kidney injury, and the WSES classes that combine grade with haemodynamic status. ^[4][8]
4. Decide when non-operative management is appropriate for liver, spleen, kidney and pancreatic injury, and when operative or damage-control management is required.
5. Recognise hollow-viscus and mesenteric injury early, explain why CT can miss it, and outline initial and definitive management.
6. Summarise the selective non-operative approach to stab and gunshot wounds, and its limits.

A useful classification for management combines three axes:

• Mechanism: blunt or penetrating.
• Anatomy: solid organ (liver, spleen, kidney, pancreas) or hollow viscus with mesentery.
• Physiology: haemodynamically stable, transient responder, or unstable.

The boxes in the middle column, above all haemodynamic stability, determine the pathway. The WSES guidelines separate minor, moderate and severe injuries using both the anatomic AAST grade and the patient's physiology; an unstable patient with even a minor anatomic lesion is treated as high risk.

Renal and urogenital injuries occur in roughly 10 to 20% of abdominal trauma in adults and children, and the kidney is involved in 65 to 90% of urogenital trauma, so the kidney is the commonest injured organ of the urinary tract.^[3] Liver and spleen are the most commonly injured solid organs in blunt trauma. Hollow viscera are less often injured by blunt force but far more often by penetrating force: traumatic hollow-viscus and mesenteric injury occurs in about 1% of blunt trauma and about 17% of penetrating trauma.^[5]

Duodenal injury is uncommon but anatomically awkward: it occurs in 0.2 to 0.6% of all trauma and 1 to 4.7% of abdominal trauma in adults, with associated injuries in 68 to 86.5% of cases.^[4] Pancreatic injury is similarly rare, occurring in under 1% of all trauma and 3.7 to 11% of abdominal trauma in adults, with associated injuries in 55 to 100% of cases.^[4] These numbers explain why a search for associated injuries and not only the obvious one is part of every primary and secondary survey.

Male patients predominate in penetrating trauma and in pancreatic and duodenal injuries; blunt injury affects all ages, with children injured by handles and handlebars, motor-vehicle and sports mechanisms.

Blunt energy produces solid-organ rupture mainly by rapid deceleration (liver and spleen against ribs, kidney at the ureteropelvic junction) and by compression (spleen, liver, pancreas against the spine). Hollow-viscus rupture from blunt force is usually a seatbelt injury or a handlebar injury in children, and mesenteric avulsion can follow.

Penetrating energy produces tract injuries with far higher rates of hollow-viscus injury and haemodynamic instability, but the pattern depends on the weapon (low-velocity stab, low or high-velocity gunshot, fragments, impalement) and on the region of the abdomen (intraperitoneal, retroperitoneal, thoracoabdominal, flank or back).

Risk factors for failure of non-operative management have been named repeatedly and should raise the intensity of monitoring, although none of them is an absolute contraindication in a stable patient: age over 55 years, high injury severity score, moderate or severe splenic injury, large haemoperitoneum, a drop in haemoglobin on arrival, anticoagulant or antiplatelet use, cirrhosis, immunocompromise, HIV and the need for transfusion.^[2][7]

• Solid-organ injury: parenchymal laceration and capsular tear release blood into the peritoneum or retroperitoneum. Bleeding may be arterial (contrast blush on CT), venous (contained haematoma that slowly expands), or venous haemorrhage that becomes unstable later. The patient's physiology - vasoconstriction, tachycardia, base excess - is what matters.
• Hollow-viscus injury: a small perforation may seal with omentum and cause only mild tenderness. Over hours the leak becomes a peritonitis, because bowel contents are enzymatically active and bacterial. Luminal contents change the picture: small-bowel content is relatively neutral, so peritoneal signs can be slow; colon content is heavier and produces earlier fever and sepsis.
• Mesenteric injury: a bowel segment can infarct late if its mesentery is torn or thrombosed, so a normal first CT or a stable patient does not exclude it.
• Biliary and pancreatic duct injury: a disrupted duct causes controlled localised leakage at first (biloma, pancreatic fistula) and chemical peritonitis or pseudocyst later, with rising amylase or lipase.
• Duodenal injury: because the duodenum is retroperitoneal, bleeding and leakage track into the retroperitoneum and flank, and peritonitis is delayed.

This explains two bedside rules: an apparently minor mechanism can hide a major hollow-viscus injury, and the abdomen must be re-examined serially rather than once.

The primary survey follows the ATLS ABCDE sequence: airway with cervical spine precautions, breathing, circulation with haemorrhage control, disability, exposure. Abdominal examination is part of circulation and continues during exposure. Eyes, ears and fingertips all matter: pale, cold extremities and a rapid, thready pulse appear before the blood pressure falls, and a trauma-dedicated team should run the survey rapidly and repeat it after every intervention.

Adjuncts after the survey include ECG, urinary catheter and, in many protocols, nasogastric decompression, a chest and pelvic X-ray, and a FAST or eFAST scan, which searches the pericardium, hepatorenal recess, splenorenal recess, pericolic gutters and pelvis for free fluid, and the chest for pneumothorax or haemothorax.

• Liver: right upper-quadrant pain or tenderness; lower rib fractures; elevated transaminases (a gross rise should prompt liver imaging). A right-sided penetrating wound track may still be solid-organ only.
• Spleen: left upper-quadrant pain or tenderness, left shoulder-tip pain (Kehr sign), left lower rib fractures.
• Kidney: flank pain, haematuria (macro or micro), a rising or falling haematocrit. Haematuria does not predict grade, and 10 to 25% of high-grade kidney injuries have no haematuria. ^[3]
• Pancreas: epigastric pain radiating to the back, rising or high amylase or lipase 3 to 6 h after injury (combined use from 3 to 6 h, repeated, is useful when imaging is equivocal). Retroperitoneal signs may be subtle. ^[4]
• Duodenum and stomach: epigastric pain, vomiting, free air or retroperitoneal air, a rising white cell count with tenderness that develops over 12 to 24 h.
• Small bowel and colon: tenderness and guarding that may be absent at first; a seatbelt sign on the abdominal wall; handlebar or direct blow; blood per rectum; unexplained fever; intolerance of enteral feeding.
• Mesentery: a mesenteric haematoma on CT, unexplained ileus, feeding intolerance, or a second rise in inflammatory markers after a normal first day.

The FAST family of examinations detects free intraperitoneal fluid (and, in eFAST, pneumothorax and haemothorax). It is quick, repeatable, non-invasive and works at the bedside. Sensitivity for small volumes is limited: on average about 620 mL of fluid is needed for detection, although skilled operators detect about 400 mL; splenic trauma series describe E-FAST sensitivity up to 91% and specificity up to 96% for detecting free fluid. FAST cannot tell blood from urine or ascites, cannot see retroperitoneal haemorrhage, and should not be relied upon to diagnose intestinal injury.^[2][5]

In blunt trauma a positive FAST in an unstable patient is an indication to go to theatre. A negative FAST never excludes intra-abdominal bleeding or injury, especially in children, where sensitivity falls markedly.

A seatbelt sign (bruising of the lower abdominal wall where the belt restrained the passenger) is associated with about a 12% chance of bowel injury, and the most commonly injured intra-abdominal structures in this group are small bowel, large bowel and spleen. A high-risk mechanism - motor-vehicle crash over 64 km/h, pedestrian struck, fall over 20 m, handlebar injury - with non-specific initial CT findings should prompt admission, serial examination, and a repeat CT after roughly 6 h if signs develop.^[5]

The first fork is clinical, not radiological: is the patient bleeding or contaminated (or both), and is the abdomen acute?

The second fork is organ-based on CT: a solid-organ haematoma or laceration versus free air, free fluid without solid organ, or mesenteric stranding pointing to hollow-viscus or mesenteric injury.

Follow the primary survey. Invasive imaging before control of bleeding is usually wrong: a FAST or chest X-ray is the limit. An unstable patient with a positive FAST and no thoracic source goes to theatre; an unstable patient with an obvious peritonitis goes to theatre. Angiography or CT are reserved for transient responders once resuscitation has stabilised them, or for after laparotomy.

• Contrast CT of abdomen and pelvis is the gold standard for solid organs and for most penetrating wounds. Triple-contrast CT is no longer routine: multidetector CT with intravenous contrast alone has sensitivity comparable to triple contrast for bowel injury and is faster, and single intravenous contrast is the standard modality. Oral and rectal contrast add time and are used selectively.
• Delayed (urographic) phases are required when kidney or ureter is in question.
• CT grading should be reported by both the AAST 2018 anatomic grade and, where vascular injury is present, the location of contrast extravasation.
• MRI or MRCP is useful for pancreatic ductal and biliary injury when CT is equivocal, and is preferred in children and pregnant patients, and for suspected biliary leak when hepatobiliary contrast MRI is available.
• Angiography is diagnostic and therapeutic: for arterial blush, pseudoaneurysm, arteriovenous fistula, or continued bleeding after damage control.
• ERCP can diagnose and treat pancreatic duct disruption and biliary leaks, including early post-trauma; endoscopic stenting, percutaneous drainage and internal drainage address many late sequelae.
• Laboratory tests include haemoglobin trends, lactate and base excess, amylase and lipase at 3 to 6 h, urine microscopy, and inflammatory markers interpreted as trends rather than single values.
• Laparoscopy diagnoses peritoneal breach, diaphragmatic injury and, in skilled hands, treats bowel and mesenteric injury; it does not exclude bowel injury reliably enough on its own.
• Diagnostic peritoneal lavage is now limited. It may be used as an adjunct to a negative laparoscopy, using biochemical markers of intestinal injury rather than red-cell counts.

In penetrating trauma, mechanism, location, depth and number of wounds guide imaging. Stab wounds to the back or flank rely on CT to assess retroperitoneal organs; anterior stab wounds can be assessed clinically. A negative CT should not be used alone to discharge a patient unless a tangential extraperitoneal tract is confirmed.

The American Association for the Surgery of Trauma organ injury scale grades an injury anatomically from 1 to 5 (or 6 for hepatic avulsion) using imaging, operative or pathologic findings, taking the highest grade seen. Advance one grade for multiple injuries to the same organ up to grade III. The 2018 revision added vascular injury - pseudoaneurysm or arteriovenous fistula, seen as contrast that fades on delayed images - and active bleeding, seen as contrast that increases on delayed images, based on the Kozar organ injury scales.^[8] Grades still need to be read alongside haemodynamic status, because stable patients with high-grade lesions are often managed without surgery, and unstable patients with minor lesions need operation.

For the kidney, AAST grades from 1 to 5 describe contusion or non-expanding perirenal or subcapsular haematoma, laceration under or over 1 cm, laceration into the collecting system, segmental infarction, shattering, hilar or main-vessel injury and devascularisation. The WSES renal section divides minor (AAST I-II), moderate (AAST III or segmental vascular injury) and severe (AAST IV-V or any parenchymal lesion with arterial occlusion) against haemodynamic status.^[3]

The WSES guidelines group injuries as minor, moderate or severe, combining anatomy with physiology:

• Liver: minor (WSES I, AAST I-II stable); moderate (WSES II, AAST III stable); severe (WSES III, AAST IV-V stable; WSES IV, any AAST unstable).
• Spleen: minor (WSES I, AAST I-II stable); moderate (WSES II-III, AAST III to V stable); severe (WSES IV, any AAST unstable).
• Kidney: minor (WSES I, AAST I-II stable); moderate (WSES II, AAST III stable); severe (WSES III-IV, AAST IV-V or any unstable).
• Duodenum/pancreas/extrahepatic biliary tree: minor (WSES I, AAST duodenal I, pancreatic I-II, biliary I-III stable); moderate (WSES II); severe (WSES III-IV).

These classes are more useful at the bedside than anatomic grade alone, because a haemodynamically unstable patient with a minor lesion goes to theatre, and a stable patient with a severe lesion can often be managed non-operatively in the right setting.

The rules that all the guidelines share:

• Patients who are haemodynamically unstable or have diffuse peritonitis after trauma go to laparotomy urgently; in blunt trauma, peritonitis means bowel injury until excluded.^[6][7]
• Haemodynamic stability, not grade on CT, is the primary indication for non-operative management.
• Non-operative management (NOM) is only attempted where 24-hour operating theatre availability, resuscitation, intensive monitoring, blood products, interventional radiology and experienced surgical staff are present (or where a rapid transfer system exists).
• Evaluation should be multidisciplinary.

Liver. In stable patients, non-operative management is the treatment of choice for minor (WSES I, AAST I-II), moderate (WSES II, AAST III) and severe (WSES III, AAST IV-V) injuries in the absence of other injuries requiring surgery; even transient responders may be considered in specialist centres with monitoring, interventional radiology and operating theatre access. A contrast CT is always required before NOM, lower-resource settings may consider NOM in stable patients with serial normal examinations and negative first-level imaging. Hemodynamically unstable non-responders (WSES IV) need operation; the first surgical aim is haemorrhage and bile-leak control and damage-control resuscitation, avoiding major resection at the first operation. Angiography may be used as first-line treatment for an arterial blush on CT and as an adjunct after damage control; in children a CT blush is not an absolute indication for angiography or embolisation. Serial clinical and laboratory examinations are mandatory during NOM. Liver hemobilia and biliary complications are managed with percutaneous drainage and ERCP.^{[1][7] [3]}

Spleen. NOM is recommended as first-line treatment for haemodynamically stable patients with blunt splenic trauma, irrespective of grade, in centres capable of intensive monitoring, immediate operating theatre and blood products, or a rapid transfer system; it is contraindicated in unresponsive instability, peritonitis, hollow-organ injury, evisceration or impalement. CT with intravenous contrast is the gold standard in stable patients. Angiography may be considered as first-line for an arterial blush at any grade, and for moderate and severe injuries in stable patients with bleeding or vascular injury on CT; strong evidence identifies age over 55 years, high injury severity score and moderate to severe splenic injury as predictors of NOM failure, so these patients need closer observation. Repeat imaging is not routine but is considered for moderate and severe injuries, falling haematocrit, vascular anomalies, coagulopathy, or impaired consciousness. Splenectomy after failed NOM or ongoing bleeding must be followed by encapsulated-bacteria vaccination and awareness of overwhelming post-splenectomy sepsis.^[2]

Kidney. NOM is the treatment of choice for all stable or stabilised minor (AAST I-II), moderate (AAST III) and severe (AAST IV-V) lesions. A contrast CT with delayed (urographic) phases is mandatory to classify the lesion and associated injuries. Isolated urinary extravasation is not by itself an absolute contraindication. Angiography with super-selective embolisation is indicated for stable patients with arterial extravasation, pseudoaneurysm or arteriovenous fistula. Unstable non-responders need operation; severe vascular injury without self-limiting bleeding also needs operation. Low-grade lesions do not need follow-up imaging; moderate and severe injuries drive imaging by clinical condition, with contrast-enhanced CT with delayed phases or ultrasound at 48 h and later. Renal injuries after penetrating lateral stab or gunshot may still be managed non-operatively in stable patients without other indications for laparotomy, with careful selection.^[3]

Pancreas. Minor pancreatic injuries without ductal involvement are managed non-operatively (WSES I, AAST I-II) in stable patients, with nutritional support; 22.6% of adults and 62 to 73% of children may require total parenteral nutrition during NOM. For WSES II (AAST III) lesions the location of the injury guides treatment; only selected very proximal body injuries in high-level centres, augmented with endoscopy and percutaneous drainage, may be tried non-operatively. Distal transections or parenchymal injuries involving the duct usually need operation, with distal pancreatectomy (with or without splenectomy) as the procedure of choice. Severe proximal or head disruptions may require delayed or staged pancreatoduodenectomy. Pseudocyst, fistula and abscess are often treated with image-guided or endoscopic drainage rather than early re-operation. Contrast CT with consideration of MRI/MRCP, amylase and lipase, and ERCP for duct assessment are the diagnostic mainstays, with a repeat CT at 12 to 24 h if suspicion remains. ^{[4] [7]}

Duodenum and extrahepatic biliary tree. Duodenal wall haematomas (WSES I-II, AAST I-II) in stable patients without other injuries can be treated non-operatively, with operative conversion if duodenal obstruction has not resolved within 14 days. Haemodynamically unstable patients, or those with peritonitis or evisceration, need immediate operation, using damage control where physiology is deranged; primary repair is preferred when technically possible, with pyloric exclusion and drainage or complex reconstruction (including pancreatoduodenectomy) reserved for destructive WSES III injuries. Gallbladder injury is treated with cholecystectomy; more severe extrahepatic biliary injuries (AAST IV-V) need hepaticojejunostomy or choledochojejunostomy, or delayed reconstruction after damage control.^[4]

Hollow-viscus injury is a clinical diagnosis supported, not replaced, by imaging. The first CT can miss about one bowel injury in five; high-risk mechanisms or seatbelt sign warrant suspicion and, if CT is non-specific, admission with serial examination, delayed CT at 6 h, and assessment of feeding tolerance. Highly specific CT findings - extraluminal air, extraluminal contrast, bowel-wall defect, metallic fragments in the wall or lumen - warrant prompt exploration. Highly sensitive findings - free fluid without solid-organ injury, mesenteric stranding, bowel-wall thickening or abnormal enhancement - are adjuncts, not sole determinants. Free fluid on FAST is non-specific for intestinal injury.

Patients with free fluid and equivocal CT, or comatose patients who cannot be examined, may need diagnostic or therapeutic laparoscopy or, sometimes, exploratory laparotomy (and exploration of the duodeno-pancreatic complex must always occur if laparotomy is undertaken). Bowel injuries should, where feasible, be repaired primarily; contraindications include destructive injury involving over 50% of the circumference, or mesenteric devascularisation. Resection and anastomosis, or stoma, are used for more destructive colon injury, with delayed primary anastomosis in damage control. In damage-controlled laparotomy, primary anastomosis carries higher leak risk the longer the abdomen remains open; leakage rates in published cohorts range from about 2 to 25% for colon and about 3% for small bowel. Damage control itself limits time and contamination by closing the bowel ends and returning later.^[5]

Penetrating wounds need non-operative management (NOM) only in centres with expertise, where the patient is haemodynamically compensated and cooperative; stab wounds are easier candidates than gunshot wounds. Peritonitis, diffuse tenderness, instability, evisceration, blood per rectum, enteric material in the wound, haematemesis, or unreliable examination (head or spinal injury, intoxication, sedation) mandate exploration. Where NOM is chosen, at least 48 h of serial examinations by consistent clinicians, vital signs and inflammatory trends are needed, and a minimum of 48 h observation is advised for gunshot wounds; discharge is appropriate after about 24 h only if the examination is reliable and minimal. Local wound exploration confirms peritoneal breach; a negative CT without a confirmed tangential extraperitoneal tract does not discharge the patient on its own. In penetrating renal injury, selective NOM has a long history and complication rates from secondary haemorrhage justify angiography as an adjunct.^[6][5]

• Right upper quadrant penetrating injury (liver) may be managed without laparotomy in patients with stable vital signs, reliable examination and minimal tenderness; selective NOM of penetrating liver injuries succeeds in many series and may use angioembolisation for a CT blush.
• Penetrating renal injury follows the same NOM principles, with operation for hilar or continued bleeding.
• Rectal injury is beyond this page but is usually excluded by proctoscopy in stable patients after blunt or penetrating pelvic trauma.

• Non-operative management is still possible if a patient is stable, with no associated injuries, negative serial physical examinations and negative basic imaging and laboratory tests; the same environment-of-care rules apply, with the option of rapid transfer.
• FAST is the realistically available bedside test in many hospitals; one should know its 620 mL average threshold for detection and treat negative scans in a symptomatic patient as unreliable.
• Major haemorrhage may require improvised damage control: topical haemostasis, warm fluid resuscitation, tranexamic acid per local protocol, and transfer to a centre with angiography and CT.
• Post-splenectomy vaccination and sepsis counselling remain important wherever splenectomy was required.

• Bleeding or re-bleeding: early deterioration is more likely in patients with ongoing resuscitation needs and is related to haemodynamic instability.
• Biliary complications: leaks and bilomas (about 3.2% of hepatic trauma), abscess (up to 4%), biliary peritonitis and sepsis; higher grades carry higher complication rates (about 1% for grade III, 21% for grade IV, 63% for grade V hepatic injury). ^[7]
• Pancreatic fistula, pseudocyst, abscess, and delayed pancreatitis after pancreatic or duodenal injury.
• Duodenal obstruction from haematoma or stricture, occasionally needing operation after 14 days of NOM.
• Renal complications: urinoma needing stenting or drainage, pseudoaneurysm or arteriovenous fistula requiring embolisation, delayed bleeding.
• Bowel-related: missed injury leading to peritonitis, sepsis, prolonged ICU stay and higher mortality.
• Post-splenectomy sepsis: rare but deadly, from loss of splenic immune function.
• Thromboembolism: pharmacologic VTE prophylaxis can be used with isolated blunt hepatic injury without increasing failure of NOM, though the ideal start time is not settled.

Mortality in blunt solid-organ injury is driven by associated trauma, brain injury and shock rather than by organ grade alone. Non-operative management of blunt hepatic injury has reported success rates of 82 to 100% in appropriately selected patients, and attempted NOM of splenic injury succeeds in about 90% of patients in high-volume centres. Hollow-viscus injury has a much smaller margin for delay: the clinical skill is to recognise the small number of patients with a missed bowel injury before it becomes septic. ^[2][7]

Primary prevention is road-traffic safety, alcohol and drug policy, occupational safety, sports protection and child-safety measures. In clinical follow-up, patients after splenectomy need vaccination against capsulated organisms and antibiotic standby courses; patients after solid-organ injury need graded return to sport (commonly 4 to 6 weeks after minor injuries and 2 to 4 months after moderate or severe injuries). There is no general population screening for traumatic injury other than trauma systems themselves. ^[2]

• Children: NOM is the first option whenever viable; solid-organ injuries are usually successfully managed non-operatively. Kidneys are more easily injured because of relatively less perirenal fat, thinner abdominal wall, unossified ribs and larger-than-adult kidney size. Pancreatic ductal injuries still determine management. Radiation burden should be balanced against missed-injury risk, with ultrasound and MR preferred where available. Post-splenectomy or post-embolisation management follows paediatric protocols.
• Pregnancy: the gravid uterus displaces bowel and changes imaging; maternal stabilisation takes priority; CT and angiography are used when clinically indicated with shielding; MRI and ultrasound are preferred first.
• Older adults: age over 55 years predicts NOM failure more reliably than many imaging findings; frailty and anticoagulation should lower thresholds for imaging and earlier escalation. ^[7]
• Immunocompromise and anticoagulation: effect on bleeding is real, but these states are not absolute contraindications to NOM in a stable patient; they justify higher vigilance.
• Polytrauma and head injury: NOM may be attempted with reliable clinical examination; if the patient cannot be examined, or if shock persists, operative management is safer.

Acute abdomen. Haemorrhagic shock. Trauma primary survey. FAST and eFAST. Liver injury. Splenic trauma. Renal trauma. Pancreatic trauma. Duodenal trauma. Mesenteric ischaemia. Damage control surgery. Post-splenectomy vaccination. Paediatric trauma.

• Abdominal trauma is separated into solid-organ bleeding and hollow-viscus leakage; mechanism changes the probability of each, but haemodynamic status and repeated examination decide management.
• Blunt trauma: solid-organ NOM succeeds in roughly 90% of attempted splenic cases and 82 to 100% of hepatic cases in well-resourced settings, provided the patient is stable and the centre is capable.
• Penetrating trauma: haemodynamic instability, peritonitis, diffuse tenderness and evisceration mandate laparotomy; otherwise selected patients, especially stab wounds, may be managed non-operatively with imaging, local wound exploration and serial examination.
• FAST is fast but insensitive for small volumes; an average of about 620 mL of free fluid is needed for detection, and it should not be relied on to diagnose bowel injury.
• Contrast CT with intravenous contrast is the gold standard in stable patients; triple-contrast CT is no longer routine, and delayed-phase imaging is needed for kidney and biliary lesions.
• AAST 2018 grading adds vascular injury, but grade does not dictate management without physiology and associated injury; WSES classes combine grade and haemodynamic status.
• All stable solid-organ lesions - liver, spleen, kidney - can be considered for non-operative management, including high-grade lesions, in the right environment; unstable or non-responding patients go to theatre (and, for solid organs, damage control).
• Pancreatic duct integrity determines management: minor injuries are observed, ductal disruption distally needs distal pancreatectomy, proximal disruption needs staged reconstruction.
• Duodenal haematoma in stable patients can be observed, with operation if obstruction does not resolve within 14 days.
• Hollow-viscus injury is missed in about one in five initial CT scans; seatbelt sign, handlebar mechanism, high-risk crash and non-specific CT demand serial examination and a repeat CT at about 6 h.
• Primary repair is preferred for bowel; resection or stoma is reserved for destructive injury, with careful attention to anastomotic leak risk after damage control.
• Low-resource management relies on stability, serial examination, basic imaging and rapid transfer rather than universal CT; after splenectomy, vaccination and parent education on sepsis remain essential.