Injury, Int. J.

Care Injured (2004) 35, 228231

Gastric rupture from blunt abdominal trauma

lvarez*, Mara Soledad Holanda,
Eva Esther Tejerina A
pez-Espadas, Maria Jose
Dominguez,
Francisco Lo

Elsa Ots, Jenaro Daz-Regan

on
s de Valdecilla
Unit of Multisystem Trauma, Department of Intensive Medicine, Marque
Hospital of Santander, Cantabria, Spain
Accepted 25 May 2003

KEYWORDS
Gastric rupture; Blunt
abdominal trauma;
Road traffic accidents;
Seat belts; Deceleration;
Splenic injury;
Thoracic trauma;
Intraabdominal sepsis;
Chemical peritonitis;
Peritoneal lavage

Summary Gastric rupture following blunt abdominal trauma is rare, with a reported
incidence of 0.021.7%. Road traffic accidents remain the most frequent cause. The
factors most often implicated in the genesis of this entity are: a history of a recent
meal, trauma to the left side of the body and an inappropriate use of seat belts. Splenic
injury is generally the most common associated injury. The high morbidity and mortality
are directly related to the number of associated injuries, delays in diagnosis and the
development of intraabdominal sepsis. We performed a retrospective study of 1300
patients with blunt trauma to the abdomen from 1973 to 2001. Seven patients sustained
a gastric rupture (five men and two women). The following associated characteristics
were analysed: mechanism of injury, clinical presentation, possible associated injuries
and postoperative complications, diagnosis methods and surgical treatment. We found
an incidence of gastric rupture of 0.5%. We emphasise an early diagnosis and aggressive
surgical treatment as a key to decreasing the mortality and morbidity from this injury.
However, in our series, the morbidity is mainly from associated injuries.
2003 Elsevier Ltd. All rights reserved.

Introduction
Gastric rupture following blunt abdominal trauma is
rare and large series in the literature report an
incidence between 0.02 and 1.7%.47,10,18,19,21,22
Road traffic accidents remain the most frequent
cause of gastric rupture and count for about 75%
of patients. The mortality rate ranges from 0 to
66%,47,10,18,19,21,22 and is mostly related to associated injuries. The factors most often implicated
are: a history of a full stomach or recent meal,
trauma to the left side of the body and an
inappropriate use of seat belts. Splenic injury is
*Corresponding author. Tel.: 34-91-5399504/658-771710;
fax: 34-942-203543.
E-mail address: evateje@latinmail.com
lvarez).
(E.E. Tejerina A

generally the most common associated injury, followed by thoracic injury. The high morbidity and
mortality associated with gastric rupture are
directly related to associated injuries, delays in
diagnosis and intraabdominal septic complications.
The purpose of this study was to review cases of
gastric rupture from blunt abdominal trauma and its
associated characteristics in our intensive care unit.

Material and methods

We performed a retrospective study of 1300
patients with blunt trauma to the abdomen treated
in our intensive care unit during the 28-year period
from 1973 to 2001. Seven patients sustained a
gastric rupture (five men and two women). The

00201383/$ see front matter 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0020-1383(03)00212-2

Gastric rupture from blunt abdominal trauma

229

following associated characteristics were analysed:

mechanism of injury, clinical presentation, possible
associated injuries and postoperative complications, diagnosis methods and surgical treatment.

failed to demonstrate such a correlation with

age. Males were injured four times as frequently
as females.22 In our series, males were involved in
five cases of gastric rupture (71.4%), with an average age of 31.8 years (range from 9 to 46 years).
Road traffic accidents are the most important
cause of gastric rupture from blunt trauma and were
involved in nearly 75% of the patients.4 In the present series, motor vehicle accidents account for
85.7% of gastric tears. Other causes are falls, direct
violence, cardiopulmonary resuscitation and seatbelt injury.4,8,21. Most reported abdominal injuries
are associated with lap belts, often worn incorrectly.1,2,8,12,15 Spontaneous rupture may also occur
in adults after an excessive consumption of food,
liquids or sodium bicarbonate.22
The stomach is a thick-wall, muscular and capacious organ with a relatively protected anatomical
position and a high degree of mobility, so it is
relatively resistant to a blunt injury, particularly
when empty. However, when the stomach is distended, as by a recent meal, blunt trauma to the

Results
The clinical results of the patients with gastric
rupture are shown in Table 1.

Discussion
We found seven gastric ruptures in 1300 patients
with blunt abdominal trauma, an incidence of 0.5%
and with a mortality rate of 0%. Several published
series47,10,18,19,21,22 reported an incidence of gastric rupture from blunt abdominal injury of 0.02
1.7%, as shown in Table 2.
Although some authors18 find that the incidence
is higher in childhood, other reported series4,21

Table 1

Clinical results of the patients with gastric rupture

Characteristics

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Patient 7

Age (years)
Sex
APACHE II
Mechanism
of injury

7
Female
Unknown
Beaten by
the snout
of a cow

24
Male
14
Motor
vehicle
accident

33
Male
9
Motor
vehicle
accident

29
Male
11
Motor
vehicle
accident

48
Female
8
Motor
vehicle
accident

42
Male
Unknown
Motor
vehicle
accident

40
Male
9
Motor
vehicle
accident

Symptoms
and signs

Peritoneal
irritation
Hematoma
in left
hemithorax

Peritoneal
irritation
Hematoma
in left lower
quadrant
Shock

Abdominal
pain
Shock

Abdominal
pain
Haematemesis
Shock

Abdominal
pain
Thoracic pain

Peritoneal
irritation
Shock

Thoracic
pain
Haematemes
Peritoneal
irritation

Diagnostic
method

Pneumoperitoneum Laparotomy
on X-ray

PL: positive

PL: positive

PL: positive

PL: positive

Pneumoperitoneum
on X-ray

Associated
injuries

No

Spleen
laceration
Left
hemidiaphragm
rupture
Pelvis fracture
Myocardial
contusion

Pancreatic
section
Liver
laceration

Spleen
rupture
Right
retroperitoneal
hematoma
Retroperitoneal Pelvis fracture
hematoma
Head injury

Spleen
laceration
Right femur
and fibula
fractures
Head injury
Head injury

Serosal tear of the

transverse colon
Left
retroperioneal
hematoma

Bilateral lung
contusion
Myocardial
contusion
Left rib fracture

Site of rupture
and other
findings

Lesser curvature
Gastric contents
in abdominal
cavity

Anterior wall

Posterior wall

Anterior wall
Gastric contents
in abdominal
cavity

Anterior and
posterior wall
Gastric contents
in abdominal
cavity

Anterior wall

Complications

Left pleural
effusion
No
6

Left pleurisy

No
No
2

Intraabdominal
abscess
No
25

No

No
9

Intraabdominal No
abscess
No
No
17
6

No
7

13

96

56

13

Mortality
Length of stay
in UCI (days)
Length of stay in 10
hospital (days)

PL: peritoneal lavage; MOSF: multiorgan system failure.

Posterior wall

19

 lvarez et al.
E.E. Tejerina A

230

Table 2

Incidence and mortality of gastric rupture in several published series

Series

Incidence of hollow
visceral injury (%)

Incidence of gastric
rupture (%)

Mortality (%)

Yajko and associates (19301975): 37 cases

Semel and Frittelli (19751981): 17 cases
Courcy and associates (8 years): 6 cases
Bransting and Morton (10 years): 6 cases

1118

0.91.7

47
12
0
50

2.9

upper abdomen can lead to an increase in intragastric pressure sufficient to cause rupture. According
to Law of Laplace (P T=R), wall tension is highest
in the parts of the stomach with the greatest radius
of curvature, such as the anterior wall and greater
curvature, predisposing them to rupture.4,9,22 In
several published series,4,13,18,19,21,22 a history of
recent meal prior to gastric rupture is significantly
related to this injury, with a reported incidence of
2776%. In our series, only one patient had a full
stomach just before injury.
Tearing by deceleration has been postulated as
other possible mechanism of injury to the stomach
directly related with the use of lap-belt-style
restraining devices.2,8,9,12,14,15 Lap belts are
designed to be worn at or below the level of the
anterior superior iliac spines, but have a tendency
to ride up over the abdomen. In this location, a
sudden deceleration may cause abrupt and direct
compression of the stomach between the seat belt,
the posterior abdominal wall and the rigid spinal
column. Lap and shoulder types of belts spread the
deceleration over a larger area so that they should
be less likely than lap belts to cause direct compression injury of abdominal viscera.2,8,14 Deceleration
also generates shearing forces at the relatively fixed
junction of the pylorus and duodenum and a simultaneous rapid forward motion of the stomach. This
last mechanism appears more likely in the case of
gastric rupture associated with the lap belt. In our
study, only one patient was wearing seat belt when
he was involved in a road traffic accident, but it is
unknown what type of seat belt he used.
The majority of patients either present in shock or
with signs and symptoms of an acute abdomen,
mainly as a result of the chemical peritonitis induced
by the spillage of gastric acid.3,4,11,13,18,2022 In the
present series, the most frequent clinical findings
were abdominal pain, peritoneal irritation and shock
(42.8%), followed by haematemesis and haematoma
on the left side of the body (28.5%), which seem to be
more specifically related to gastric rupture. Subcutaneous emphysema may appear via the mediastinum when rupture occurs near the cardioesphageal
area.13,18,22 Free intraperitoneal air on abdomen and
chest films may be absent in 29.483.3% of the

0.4

cases.4,6,18,19,21 This may be attributable to the fact

that most trauma patients have radiographic examinations performed while in the supine position. In
our series, there was a pneumoperitoneum in five
cases (71.4%). Aspiration of a dark peritoneal lavage
fluid by the action of gastric acid on haemoglobin, a
turbid fluid as well as the presence of bile or amylase,
may suggest gastric rupture.4,16,17,21 In the present
study, haemoperitoneum was suspected on clinical
findings and was confirmed with a positive peritoneal
lavage in four patients. Ultrasound may be useful to
detect abdominal fluid. CT-scan is especially valuable if the diagnosis of gastric rupture is delayed.1,20
Splenic injury is generally the most common
associated injury, followed by significant thoracic
injuries, mainly to the left side of the body.4,16,17,21
Thoracic trauma is a major contributing factor
towards substantial morbidity and mortality associated with gastric rupture.4,9 Splenic injury was
present in three of our patients (42.8%), trauma to
left side of the body was present in four patients
(57.1%) and thoracic trauma to this same side in two
patients (28.5%).
The majority of complications are directly
related to the massive intraperitoneal contamination with undigested food and gastric acid, causing a
chemical peritonitis.6,16,20 Delay in diagnosis
increases the period of peritoneal contamination
and adds to the mortality.1,21 The most common
complication is intraabdominal abscess formation.
Gastric fistulae may also occur. Two of our patients
(28.5%) developed intraabdominal abscesses.
Blunt gastric rupture can occur in any portion of
the stomach. It usually occurs as a single lesion,
which is commonly debrided and repaired by primary closure. It is unusual a gastric rupture with
extensive damage requiring partial gastrectomy.16,19 The anterior gastric wall is most often
involved, reported to be 40% in the reviewed literature,4,6,18,22 as shown in Table 3, followed by
greater curve (23%), lesser curve (15%), and posterior wall (15%). However, the greater curvature is the
site most often affected in the paediatric age
group.21 The injury occurs more commonly on a full
stomach leading to peritoneal contamination with
solid food particles as had occurred in three of our

Gastric rupture from blunt abdominal trauma

Table 3

231

Site of gastric rupture in several published series

Series

Anterior
wall (%)

Greater
curvature (%)

Lesser
curvature (%)

Posterior
wall (%)

Yajko and associates (19301975): 37 cases

Semel and Frittelli (19751981): 17 cases
Courcy and associates (8 years): 6 cases
Brunsting and Morton (10 years): 6 cases

26
53
33
60

16
29
33
20

32
6
0
0

11
12
33
20

cases. In the present series, the anterior wall of the

stomach is the most common site of rupture (57.1%),
Similar to other reviewed series, followed by posterior wall (42.8%) and lesser curve (14.2%). In our
series, greater curve was not affected in any patient.
Some authors recommend adequate debridement
of the margins of the laceration and a postoperative
gastric decompression is also advised. It is also
important to inspect the entire surface of the stomach, even the posterior surface. To prevent the
occurrence of an intraabdominal abscess the abdominal cavity needs an extensive mechanical irrigation
with large amount of a diluted solution of betadine.6,20. In the case of abscess formation, an aggressive approach of early reoperation and drainage is
emphasised.4,19,20 Primary gastric closure was performed in all seven patients in our series.
The mortality associated with gastric rupture has
been reported to range from 0 to 66%.47,10,18,19,21,22
It is mostly related to associated injuries, septic
complications and, less frequently, to fatal shock.4,17
In the present study, we observed a mortality rate
of 0%.

Conclusions
We report an incidence of gastric rupture of 0.5% of
all blunt trauma admissions in our unit, similar to
that seen in the reviewed literature. We agree with
other authors in emphasising an early diagnosis and
aggressive surgical treatment as a key to decreasing
the mortality and morbidity from this injury. However, in our series, the morbidity is mainly from
associated injuries.

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