The incidence of penetrating abdominal trauma accounts for less than 10 percent of all trauma patients, with about half due to stab wounds. Stab wounds that penetrate the abdomen can be difficult to assess, leading to delay in identifying injuries and delayed complications that can add to morbidity. Injuries caused by stab wounds can be life threatening due to bleeding, auto digestion, inflammation, fluid sequestration, contamination, and peritonitis.¹ Although 50 to 70 percent of patients with abdominal stab wounds violate the peritoneum, only 25 to 33 percent of patients with abdominal stab wounds have therapeutic laparotomies, making appropriate assessments critical to treatment modalities.⁶

Definition of Regions

Stab wounds can be divided anatomically, anterior (axillary lines laterally and from costal margins to groin crease), flank and back. Anatomically, most anterior stab wounds occur in the left upper quadrant, followed by left lower quadrant, right upper and right lower.¹ The diagnostic and therapeutic approach heavily depends on the involvement of the abdominal region, with the upper limit of the abdomen defined by the diaphragm, which can rise up to the level of the nipples during exhalation.

Diagnostic Approach

A common adage in trauma is that the most missed injury is the second one. It is crucial to undress the patient so as not to miss additional injuries that may be obscured or overlooked. On physical exam, the location of stab wounds, evaluation for tenderness or signs of peritonitis, and a complete vascular exam are important.

Serial abdominal exams can be utilized to help with diagnosis of evolving injuries.^2,3 Unfortunately, physical exam alone may be difficult to determine the appropriate course of action due to confounding factors. Various imaging modalities can aid in diagnosis and drive therapeutic approaches.⁷

X-ray can be used to assess thoracoabdominal and abdominal injuries to identify, pneumothorax, hemothorax, or cardiovascular injury. X-ray can also show signs of gastric contents in the thorax or a gastric tube tracking into the chest cavity to correlate with a diaphragmatic injury. Air under the diaphragm can also be seen in the setting of bowel perforation.

Ultrasound has evolved into a dynamic tool through the extended Focused Abdominal Sonography for Trauma (eFAST) exam.^8,9 eFAST can lead to bedside interventions and identify patients with a strong predictor of injury requiring an operative repair.¹⁰

Computerized tomography (CT) scan with contrast (IV, oral, and/or rectal) is a focal point of diagnosis in trauma. Triple contrast CT scan has cited the highest accuracy, however, newer high resolution multidetector scanners with IV contrast alone are comparable in sensitivity and specificity.³ CT may also define intraperitoneal injuries that may be non-operatively managed. CT tractography, a CT scan in which contrast is injected into the stab wound, carries a high false negative rate and should not be used as the sole determinant for decision making. Delayed phase imaging for CT scans can identify collecting system injuries.² Penetrating trauma to the suprapubic region in stable patients should undergo a cystography.

Another approach to evaluate abdominal stab wounds is local wound exploration (LWE). This technique helps determine if the fascia was penetrated and peritoneum violated. There have been trials that show that sensitivity and specificity of LWE for peritoneal violation are 100 percent.⁴ Even with cooperative patients, LWE is rarely feasible in the emergency department setting as it requires a sterile field, equipment, appropriate lighting, staffing, and anticipation that the incision may need to be extended.

Exploratory laparotomy remains the gold-standard for diagnostic evaluation. This surgical approach evaluates certain injuries that can only be excluded by direct observation, such as diaphragmatic injury.^1,3 There are risks with this invasive approach such as infection, iatrogenic injury, abdominal pain, and sequalae of abdominal surgery. The use of exploratory laparoscopy is a less invasive alternative to laparotomy.

Therapeutic Approach

The role of treatment for abdominal stab wounds has changed from an early, definitive laparotomy to damage-controlled resuscitation and non-operative management. Exploratory laparotomy or laparoscopy is recommended in patients with hemodynamic instability, signs of peritoneal irritation, hematemesis, or blood per rectum after an anterior stab wound.² In those who are stable, one can utilize the various diagnostic evaluations mentioned earlier.¹⁵ Operating on stab wound victims based on clinical status and diagnostic tools leads to a decrease in nontherapeutic laparotomies, complication rates, and hospital length of stay.^16,17

Serial clinical exam is a possible management approach that can be utilized to avoid laparotomy. Re-examination should include an abdominal, neurological, and vascular exam.¹⁸ This approach depends on consistent, trained evaluation but can be logistically challenging.

As the liver is the largest solid organ in the abdomen, it is the most frequently injured and its extensive vascular supply makes injuries to this organ challenging to manage.¹⁷ Due to this, mortality of operative liver injuries remains high. One adjunct therapy that can help with liver injury is angiographic embolization (AE).⁵ Like the liver, the spleen’s size makes it a major target and cause of morbidity and mortality in stab wound injuries. Splenectomy is the treatment in patients with hemorrhagic shock and splenic trauma. In hemodynamically stable patients, splenic salvage can be pursued with serial imaging and AE.^2,5

Vascular injuries from penetrating abdominal trauma are uncommon, however they can be lethal. These injuries demand rapid control of bleeding and resuscitation. Vascular injuries can be accompanied by hematomas or active hemorrhage. Management will be dictated based on the type of bleed, stability of the patient, and location of injury. AE can also be a diagnostic and therapeutic adjunct for these patients.^3,5

New Innovations in Approach and Management

As trauma patients’ care evolves, so does the diagnostic and therapeutic approach to patients who suffer stab wounds. For patients who develop hemodynamic instability or cardiac arrest due to abdominal stab wound, resuscitative endovascular balloon occlusion (REBOA) can be placed to aid resuscitation and stabilize to bridge to further diagnostic and therapeutic interventions.^12,13,14 In lieu of a resuscitative thoracotomy and supradiaphragmatic aortic clamp, REBOA can obtain control above the level of the diaphragm to control hemorrhage. Studies have shown a survival benefit over resuscitative thoracotomy, especially in patients who have not arrested, although further studies are needed for this recommendation to be more definitive.¹²

Another developing approach for immediate diagnosis and intervention is mobile digital subtraction angiography. This technique utilizes angiography for dynamic real time diagnosis and provides the ability for therapies such as AE, endovascular aortic repairs, and stenting.⁵ Subtraction angiography and endovascular therapies for trauma depend on multiple factors such as location and equipment, skill and availability of proceduralist, potentially transferring the patient, and capacity for hybrid approaches in trauma.

Conclusion

In conclusion, patients with abdominal stab wounds must be assessed in a methodical manner utilizing appropriate exposure, physical exam, imaging modalities to best determine appropriate management. Management has evolved to focus on stabilizing the patient, minimally invasive interventions, and holistic evaluations. As the field of emergency medicine and traumatology grows, so will diagnostic and therapeutic interventions.

Dr. Doko is an emergency physician currently pursuing an anesthesia critical care fellowship at Emory School of Medicine.

Dr. Dave is a dual-boarded emergency and surgical critical care physician who is an intensivist at Emory School of Medicine and emergency medicine attending at Grady Memorial Hospital.

References

1. Lotfollahzadeh S, Burns B. Penetrating abdominal trauma. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 3, 2023.
2. Martin MJ, Brown CVR, Shatz DV, et al. Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018;85(5):1007-1015.
3. Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68(3):721-733.
4. Sarici İS, Kalayci MU. Is computed tomography tractography reliable in patients with anterior abdominal stab wounds? Am J Emerg Med. 2018;36(8):1405-1409.
5. Morozumi J, Ohta S, Homma H, et al. Introduction of mobile angiography into the trauma resuscitation room. J Trauma. 2009;67(2):245-251.
6. da Silva M, Navsaria PH, Edu S, Nicol AJ. Evisceration following abdominal stab wounds: analysis of 66 cases. World J Surg. 2009;33(2):215-219.
7. Feliciano DV. Abdominal Trauma Revisited. Am Surg. 2017;83(11):1193-1202.
8. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998;228(4):557-567.
9. Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma. 1999;46(3):466-472.
10. Udobi KF, Rodriguez A, Chiu WC, Scalea TM. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma. 2001;50(3):475-479.
11. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482.
12. Brenner M, Inaba K, Aiolfi A, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma‘s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry [published correction appears in J Am Coll Surg. 2018 Oct;227(4):484]. J Am Coll Surg. 2018;226(5):730-740.
13. Manley JD, Mitchell BJ, DuBose JJ, Rasmussen TE. A Modern Case Series of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Out-of-Hospital, Combat Casualty Care Setting. J Spec Oper Med. 2017;17(1):1-8.
14. Cannon J, Morrison J, Lauer C, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock. Mil Med. 2018;183(suppl_2):55-59.
15. Cothren CC, Moore EE, Warren FA, Kashuk JL, Biffl WL, Johnson JL. Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds. Am J Surg. 2009;198(2):223-226.
16. Kobayashi LM, Costantini TW, Hamel MG, Dierksheide JE, Coimbra R. Abdominal vascular trauma. Trauma Surg Acute Care Open. 2016;1(1):e000015. Published 2016 Jul 20.
17. Martin MJ, Brown CVR, Shatz DV, et al. Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018;85(5):1007-1015.
18. Herfatkar MR, Mobayen MR, Karimian M, Rahmanzade F, Baghernejad Monavar Gilani S, Baghi I. Serial Clinical Examinations of 100 Patients Treated for Anterior Abdominal Wall Stab Wounds: A Cross Sectional Study. Trauma Mon. 2015;20(4):e24844.