Hollow visceral injuries produce symptoms by the combination of blood loss and peritoneal contamination. Perforation of the stomach, small bowel, or colon is almost always accompanied by some blood loss such as from a concomitant mesenteric injury. Blood loss from the mesentery can be substantial. Gastrointestinal contamination will produce physical findings over a period of time. This assumes that the patient is awake and alert enough to complain of pain and demonstrate tenderness. Patients with closed head injuries or those who are significantly intoxicated may not demonstrate physical findings for hours or days after admission. In addition, patients with substantial injuries elsewhere may be distracted from their abdominal pain for a number of hours.
Gastrointestinal injuries may take as long as 6 to 8 h to manifest clear findings on physical examination. Gastric injuries produce abdominal symptomatology by chemical irritation when acidic contents are spilled into the abdominal cavity. This often occurs early in the treatment course but may take more time if patients are on H2 blockers. The fluid within the small bowel and colon produce symptomatology by virtue of its bacterial content. Thus peritonitis is suppurative. Inflammation may take some hours to develop. The duodenum, on the other hand, is located within the retroperitoneum. If duodenal injuries are contained, there may be few early symptoms. Thus duodenal injuries represent a special subset of hollow visceral injuries that require more complete investigation, including the maintenance of a high index of suspicion.
The bladder is a hollow viscus whose fluid is not an irritant. Urine can be in the peritoneal cavity for days before producing symptoms. Retroperitoneal bladder injuries will produce virtually no symptoms. The bladder wall is tremendously well vascularized. Thus almost all patients with bladder injuries have significant hematuria. Intraperitoneal bladder rupture usually produces fluid in the abdomen. The amount of fluid will depend on the amount of urine in the bladder at the time of impact. If the bladder injury is contained within the retroperitoneum, there will be no free fluid. Physical examination will rarely diagnose a bladder injury. More sophisticated diagnostic testing is necessary to make this diagnosis.
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