What is the management and treatment for an abdominal bruise?

Management of Abdominal Bruise

For an abdominal bruise in a hemodynamically stable patient without signs of peritonitis or active bleeding, non-operative management with close clinical and radiological monitoring is the recommended approach to reduce morbidity and mortality. 1

Initial Assessment and Risk Stratification

The presence of an abdominal bruise requires immediate evaluation to determine if it represents superficial trauma or indicates underlying intra-abdominal injury:

• Obtain detailed trauma history including mechanism of injury, as high-energy mechanisms (motor vehicle accidents, falls from height) carry up to 75% risk of associated internal injuries that may not be clinically apparent initially 2
• Assess hemodynamic stability with vital signs, as instability (systolic BP <90 mmHg, tachycardia) mandates immediate surgical intervention 3
• Examine for specific clinical signs: transverse abdominal bruising suggests seatbelt injury with high risk of hollow viscus perforation; periumbilical ecchymosis (Cullen's sign) may indicate intraperitoneal hemorrhage or pancreatitis 4, 5
• Rule out non-traumatic causes in spontaneous bruising without trauma history, including coagulopathy (acquired hemophilia A with factor VIII deficiency), vitamin K deficiency, or underlying abdominal pathology 6, 7

Diagnostic Imaging Algorithm

For hemodynamically stable patients with abdominal bruising:

• CT scan with IV contrast is the gold standard and should be performed immediately in all patients with suspected torso trauma or high-risk mechanism, with 99.63% negative predictive value for surgical intervention 2, 1
• FAST ultrasound has limited utility with only 56-71% sensitivity for detecting intra-abdominal injuries, meaning a negative FAST cannot exclude significant pathology 2
• Never delay imaging for "observation" as occult injuries can deteriorate rapidly, with mortality increasing approximately 1% every 3 minutes when significant hemorrhage is uncontrolled 2, 3

For hemodynamically unstable patients:

• Immediate exploratory laparotomy is mandatory if FAST shows free fluid with hemodynamic instability, as CT scanning is contraindicated and delays increase mortality up to 70% 3, 1

Non-Operative Management Protocol

In patients without active bleeding, peritoneal signs, or bowel perforation, non-operative management reduces morbidity and mortality compared to surgical intervention: 1

• This approach is successful in >80% of abdominal trauma cases, including 90% of renal injuries and 70-80% of splenic/hepatic injuries 1
• Even severe injuries (Organ Injury Scale 4-5) can be managed non-operatively with close monitoring 1
• Serial clinical examinations and repeat imaging are essential, as subsequent intervention may be needed without representing failure of the strategy 1

Specific Management Based on Findings:

For solid organ injuries with documented active bleeding on CT:

• Therapeutic angioembolization should be considered as first-line intervention in hemodynamically stable patients, significantly reducing failure rates of non-operative management 1
• This is particularly effective for hepatic injuries with contrast extravasation, though remains controversial for splenic trauma 1

For suspected hollow viscus injury:

• Exploratory laparoscopy is indicated when CT cannot rule out bowel perforation, as surgical delay beyond 24 hours increases mortality fourfold 1
• Development of pneumoperitoneum mandates immediate laparotomy 1

Critical Monitoring Requirements

For patients at risk of intra-abdominal pressure elevation:

• Monitor intra-abdominal pressure in ICU to detect abdominal compartment syndrome early 1, 8
• Pressure >25 mmHg with organ dysfunction defines abdominal compartment syndrome requiring urgent decompression 8

Common Pitfalls to Avoid

• Never rely on clinical examination alone in blunt trauma from high-energy mechanisms, as associated injuries may not be clinically apparent 2
• Do not discharge patients without imaging when any abdominal pain follows significant trauma, as delayed presentations occur in 0.2-0.5% of cases 2
• Avoid preventive angioembolization in all cases—it should be reserved for documented active bleeding, as benefit is unproven in high-grade renal injuries and controversial in splenic trauma 1
• Consider coagulopathy workup including factor VIII levels and coagulation studies in spontaneous non-traumatic bruising 6