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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 22-26

Analysis of pattern and outcome of abdominal trauma in a tertiary hospital in Kano, Northwestern Nigeria


Department of Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication4-Apr-2018

Correspondence Address:
Dr. A A Sheshe
Department of Surgery, Bayero University, Kano/Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_22_17

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  Abstract 


Background: Abdominal injuries are common surgical emergencies in casualty units of most developing countries. This is due to the high incidence of trauma arising from increased road traffic accidents and violent crimes as a result of socioeconomic and political conflicts. The aim of this study is to evaluate the pattern and outcome of abdominal trauma in our environment and recommend ways for improving the trauma services.
Patients and Methods: The case records of 46 patients admitted during a period of 2 years, just before the onset of insurgency (2010–2011) and managed in Aminu Kano Teaching Hospital were retrospectively studied for demographic characteristics, modes of injury, organs injured, treatments, and outcome. Data was collected on to Microsoft Excel 2010. Simple statistical parameters were calculated.
Results: A total of 46 patients were studied; 35 (76.1%) of which had penetrating abdominal trauma (PAT) and 11 (23.9%) had blunt abdominal trauma (BAT). The male: female ratio was 8.2:1 with peak age range of 20–29 years. Stab wounds accounted for 46% and gunshot for 31% of PAT, while road traffic accidents (RTA) accounted for 82% of the BAT group. The intestine (41%), the liver (25%) are the most common organs injured in PAT, while the spleen and intestine each constituting 29% are the most frequent injured in BAT. Ninety-one percent had exploratory laparotomy, while (4) 9% were successfully managed non-operatively. The post- operative mortality rate was 16.7%.
Conclusions: Abdominal trauma commonly affects the young adult males and remains a major source of morbidity and mortality in our society. Communal conflicts and road traffic accidents are the major causes. Promotion of ethno-religious harmony and road traffic education at the community level and establishment of trauma systems in hospitals will help forestall this trend.

Keywords: Abdominal trauma, incidence, outcome


How to cite this article:
Sheshe A A, Yakubu A A. Analysis of pattern and outcome of abdominal trauma in a tertiary hospital in Kano, Northwestern Nigeria. Arch Int Surg 2017;7:22-6

How to cite this URL:
Sheshe A A, Yakubu A A. Analysis of pattern and outcome of abdominal trauma in a tertiary hospital in Kano, Northwestern Nigeria. Arch Int Surg [serial online] 2017 [cited 2021 May 15];7:22-6. Available from: https://www.archintsurg.org/text.asp?2017/7/1/22/229177




  Introduction Top


Kano city is a major commercial centre in the North-western region of Nigeria. It has a population of nine and a half million according to the 2006 National Population and Housing Census conducted by the National Population Commission.[1] There are three tertiary health centres, one of which also serves as a teaching hospital; all located within the metropolis. By virtue of being a teaching hospital many patients are received from all parts of the state and bordering states - either self-referred or hospital-referred. A World Health organization (WHO) study in 1999 identified trauma as responsible for 10.1% of global deaths, and listed injury as a consistent health problem in all parts of the world irrespective of their economic status.[2] The region of the abdomen is particularly vulnerable to injury, and is therefore a commonly encountered challenge in surgical practice.[3],[4],[5]

The incidence of abdominal trauma has been on the increase in most major cities in West Africa due to favourable social and political factors, leading to civilian unrest, conflicts, and injuries.[6],[7],[8] Abdominal trauma is a major cause of mortality and morbidity especially with multiple organ involvement. The number of deaths due to trauma is similarly noted to be on the increase in Nigeria.[5],[9]

In general, injury to the abdomen may result from either a blunt force or penetrating objects. In developing countries many factors contribute to heightened morbidity and mortality including poor pre-hospital care, delayed presentation and treatment, challenges in diagnosis of BAT and associated multiple organs and extra abdominal injuries.[10],[11] In order to counter these factors, it is necessary to establish proper trauma systems that will expedite treatments in trauma victims.

The aim of this retrospective review is to study the pattern, surgical management, and outcome among patients with abdominal injury during the period preceding the onset of insurgency, and recommend ways of improvement.


  Patients and Methods Top


This study is a retrospective case records review of 46 patients out of 58 managed for abdominal trauma in the General Surgery Unit of Aminu Kano Teaching hospital over a period of 2 years (2010–2011). The records of 12 patients were not included due to loss of most of the information needed. Data was obtained from Department of Health Records, casualty, wards, and theatre records. The following information was retrieved; age, gender, cause of injury, circumstance of injury, hemo-dynamic stability, treatments, and outcome. Data collected was entered into Microsoft Excel 2010 Inc following which relevant statistical parameters were calculated.


  Results Top


Age and sex distribution

A total of 46 patients with complete documents constitute the subjects studied. Peak age group for both penetrating abdominal trauma (PAT) and blunt abdominal trauma (BAT) was 20–29 years. About 70% of the patients are between the age range of 10–29 years. The male:female ratio was 8.2:1 [Table 1] on age /sex distribution].
Table 1: Sex and Age Distribution

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Presentations: Hemodynamic instability was recorded in 13 (29%) of the patients at presentation as evident by hypotension, low pulse pressure, tachycardia, and shock index >1. Patients with PAT presented with wounds of the abdomen or low chest wall with evisceration of Omentum or small intestine in some instances. This group of patients presented earlier – most of them 26 (74%) within 24 hrs of injury. Blunt abdominal trauma victims are often delayed; about 6 (55%) presented between 24 to 48 hrs and 2 (18%) after 48 hrs of injury. One patient with BAT came at the 7th day of trauma. BAT patients mostly presented with features of peritonitis.

Causes and nature of injury

The majority of the abdominal injuries were from penetrating trauma - 35(76%), while BAT accounted for only 11 (24%).

The commonest cause of injury in PAT was stab wound in 16 (46%) and gunshots in 11 (31%) [Table 2] on causes of PAT]. The circumstances of injury in PAT were mostly during ethno religious crisis in 23 (65%) instances and armed robbery attacks in 7 (20%). BAT were mostly following RTA in 9 (82%), fall from height 1(9%), and collapsed building in 1 (9%) patient.
Table 2: Causes of Penetrating Abdominal Injury

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Types of injuries sustained

The total number of organs injured among 42 patients was 58. [Table 3]. Among these, PAT accounted for 44 (76%) while 14 (24%) injuries were found in BAT. Most patients [32 (76%)] have solitary organ injury. Multiple organ injuries were more common in PAT than in BAT. In PAT, the usual combination involved the liver, small bowel, and kidneys, while in BAT, the spleen and small bowel were the commonest combination of injuries. The most frequent single organs injured in PAT were intestines (41%) followed by liver (25%) and diaphragm (9%). However, in BAT the organs injured were spleen (29%), small intestine (29%), and kidneys (14%). Thoraco-abdominal injuries were found in 7 (15.2%) patients, while skeletal injuries were found in 5 (10.9%) patients. The abdominal wall wound in PAT was mostly in the para-umblical region, right upper quadrant, lumbar, iliac fossae, and low chest wall.
Table 3: Single Organs injured

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Treatments

Non- operative management was offered to 4 patients; two were due to PAT as a result of stab with no violation of the peritoneum, additionally there were no features of peritonitis, peritonism or hemo-dynamic instability in both. The other two patients with BAT had liver laceration with sub capsular hematomas (grade II) seen on abdominal ultrasound scan and were also managed successfully without operation.

A total of 42(91%) patients with PAT and BAT had emergency abdominal exploration after due resuscitation and relevant investigations. Specific surgery depending on the organ/organs injured, in addition to treatment of other associated extra abdominal injuries were done. Re-exploration was affected in two patients due to reoccurring abdominal abscess with missed duodenal injury in one. The major operations done were resection and anastomosis (14), repair of liver lacerations in 13, hemi-colectomy (5), colostomy (3), and splenectomy in 4 patients. Additionally, left thoracotomy was done in 2 patients due to thoraco-abdominal injuries. One patient with neck lacerations had exploration and repair of vascular injuries. A total of 5 patients had chest tube thoracostomy.

Two patients had repeat laparotomy due to a missed duodenal injury and intra-abdominal abscess in one, and the other due to abscess re-collection resulting from colonic injury.

Outcome

The duration of hospital stay ranged from 1 to 74 days with a mean of 17.1 days. Two patients developed intra-abdominal abscesses that required re-exploration, repair, and drainage. Wound infection was recorded in 8(19%) contributing to prolonged hospital stay. Post operative mortality was recorded in 7 (16.7%) patients, among which 4 patients died due to gunshot with multiple injuries, while two died from uncontrolled hemorrhage and one from septic shock. These patients additionally had multiple organs injuries and hemo-dynamic instability.


  Discussion Top


Abdominal trauma continues to be a common presentation in causality units all over the world. In recent times, the incidence in the tropics has been increasing especially due to increase in urbanization, high speed travelling ethno- religious violence due to political and economic adversity leading to frustrations and social conflicts.[7],[12] The findings of this study of sex and age are similar to those seen in most major cities of West Africa. Seventy percent of the victims are in their second or third decades of life, similar to reported studies elsewhere.[3],[7],[8],[10] These age groups are the most dynamic members of the society who are more likely to be involved in motor vehicle accidents and interpersonal violence. Abdominal trauma is therefore predominantly a disease of the young adult male.

The findings in this study of the causes of abdominal injuries were similar to other studies in northern Nigeria.[7],[8],[13] However, the prevailing changes in economic condition have heightened the number of violent injuriesarising from communal fights, assaults, and armed robberies are becoming more prominent and they accounted for 70% (32) in this study [Table 2]. A previous study in our centre by Edino [8] similarly found PAT to be the most common mechanism of abdominal injury as reported by other workers,[4],[10],[11] mainly from stab rather than fire arms. This was different from what was found in other parts of Nigeria and the western world.[6],[14] In our environment, traditional weaponry like knives, machetes, cudgels, and swords are mostly used. Two communal conflicts took place during the period studied and might have contributed to the high figure recorded. Similarly, reports have indicated evidence of rising domestic violence in most major cities in the country,[7],[8] which may constitute additional challenge to healthcare delivery. Cow-gore injury is common among Fulani herdsmen and is regarded as an occupational hazard. Sabo et al. had reported 32 cases of cow-gore injuries amongst this tribe in northern Nigeria, half of these involved the abdomen.[15]

Road traffic accidents remain the single commonest cause of blunt abdominal injury, responsible for 9 (82%) in this study, similar to experiences in other centres in Nigeria.[6],[7],[8],[16],[17] It is difficult to ascribe this to poor roads and the road-worthiness of the vehicles alone since similar accidents are frequent occurrences in other developed parts of the world.[18]

A distinct observation is that 72% of patients with PAT presented within 24 hrs of the injury, in contrast to those with BAT whose presentation is often delayed. About 45% of them presented after 48 hrs. This may be because of delay in referral, challenges in transportation, and lack of facilities and personnel to manage such patients in distant and less urbanized settings. It is not uncommon in patients with BAT for diagnosis to be delayed due to evolving nature of the injury.[19],[20]

The use of diagnostic peritoneal lavage (DPL) was low in our setting; only one patient had DPL. This may be because of delayed presentation and frank peritoneal signs at presentation. DPL assists in early diagnosis of intra-abdominal injuries with an outstanding accuracy rate of 97%.[19],[20] DPL has been shown to be more accurate than CT scan in diagnosing early viscus perforations and identifying patients that need early surgical explorations.[20] Abdominal USS has a high diagnostic performance in emergency setting for patients with BAT [21] and is commonly used in the care of our patients.

Liver and spleen are the most common solid organs injured in both PAT and BAT, respectively, similar to other reports.[22] There was a higher small intestinal involvement than large intestinal injuries. Ameh et al. had similarly reported small intestinal than large intestinal injuries in children.[13]

There was high diaphragmatic injury 9% in PAT in this study and one duodenal injury was missed during the initial laparotomy. High index of suspicion is needed to diagnose and effectively manage duodenal and diaphragmatic injuries.[23] This is particularly true when penetrating wound is present in the lower chest or upper abdominal wall with or without liver or splenic injuries.[22] The missed duodenal injury buttresses the fact that experienced surgeon must be involved in the management of abdominal trauma.

Ninety-one percent of our patients underwent emergency laparotomy. Four patients were managed non-operatively. While non-operative management (NOM) has been considered the standard of care for BAT patients,[19] it is labour intensive especially in a busy casualty unit and paucity of skilled manpower. Recently, selective NOM of stab wounds to the abdomen has been the standard of care in the United States, as about 50% of stab wounds to the anterior abdominal wall can be safely managed non-operatively.[14],[19] Similarly, all the patients in this study with retro-peritoneal hematoma were managed conservatively as experienced by other researchers.[24]

The mortality of 16.7% among patients with abdominal injuries was recorded and was comparable to reports in the literature.[7],[17] This was mainly associated with gunshot, shock, multiple injuries, sepsis, and lack of facilities for immediate resuscitation. Previous mortality rates reported in Nigeria compared well with this study.[7],[25] It is observed that gunshot injuries, shock, multiple organ involvement, and extra-abdominal injuries constitute important factors in the mortality rate.[26],[27] An average mortality rate of 5% was reported for most level 1 trauma centers.[28] This calls for the need to establish trauma systems that will go a long way in improving morbidity and mortality associated with trauma care in Nigeria.

The non-availability of all the patient records for analysis of data and the failure to compute injury severity scores were important limitations of this study.


  Conclusion Top


Abdominal trauma commonly affects the young able bodied males in our society and remains a major source of morbidity and mortality. Communal conflicts and road traffic accidents are the major causes among others. The setting of an effective trauma care system in the region coupled with promotion of ethno-religious harmony and road traffic education will improve the morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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