International Journal of Clinical Medicine, 2012, 3, 426-430
http://dx.doi.org/10.4236/ijcm.2012.35079 Published Online September 2012 (http://www.SciRP.org/journal/ijcm) 1
Penetrating Abdominal Trauma: Experience in a Teaching
Hospital, Calabar, Southern Nigeria
Maurice Asuquo, Mark Umoh, Victor Nwagbara, Gabriel Ugare, Cyril Agbor, Emmanuel Japhet
Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria.
[e-mail], [e-mail]
Received May 28th, 2012; revised June 30th, 2012; accepted July 15th, 2012
ABSTRACT
Background: Penetrating abdominal trauma (PAT) typically involves the violation of the abdominal cavity by a gun-
shot wound (GSW) or stab wound. Recently several studies have favored a more conservative approach as opposed to
mandatory exploratory laparotomy. Methods: Patients admitted in the University of Calabar Teaching Hospital
(UCTH), Calabar, with PAT from January 2008 to December 2010 were prospectively studied based on a questionnaire.
The total number of patients with PAT was compared with total number of emergencies, traumatic injuries and ab-
dominal trauma seen during the same period. Results: A total of 48 patients presented with abdominal trauma: PAT 29
(60%) and blunt abdominal trauma (BAT) 19 (40%). The ages of the patients (28 male, 1 female) ranged from 3 - 62
years (mean 28.1 years). Gunshot wound (GSW) 11 (38%) patients, stab wound 8 (27.6%) patients and machete cut 4
(13.8%) patients ranked first, second and third respectively as causes of PAT. The commonest organ injury was perfo-
ration of the small intestine. Four (13.8%) patients were managed conservatively while 25 (86.2%) patients had laparo-
tomy. The duration of admission ranged from 2 - 19 days (mean 10.5 days). Morbidity [surgical site infection (SSI)]
and mortality were recorded in 2 (6.9%) and 3 (10.3%) patients resp ectively. Conclusion: Key areas that require atten-
tion have been highlighted. Revamping the ailing economy and gainful employment for youths are paramount areas that
require prompt, dedicated and sustained intervention for reduction in violent crimes.
Keywords: Penetrating Abdominal Trauma; Pattern; Management
1. Introduction
Penetrating abdominal trauma (PAT) typically involves
the violation of the abdominal cavity by a gunshot wound
(GSW) or stab wound [1,2]. The frequency of PAT
across the globe relates to industrialization of develop ing
nations, weapons available and significantly to the pres-
ence of military conflicts. Therefor e the frequency varies
[2,3].
Baudens ML performed the first exploratory laparo-
tomy for trauma. Management has gone full cycle from
exploration for all cases of penetrating trauma to the
present maxim that “not everybody with a hole in the
abdomen needs exploration” [4,5]. The mandate for sur-
gical exploration for all PAT has been questioned [6]. In
1960, Shaftan suggested selective management of pa-
tients with abdominal stab wound after observing an in-
creased rate of laparotomy without identifiable injuries
[2]. Recently several studies have favored a more con-
servative approach as opposed to mandatory exploratory
laparotomy [7,8]. More recently, expectant management
has been used in the treatment of specific GSW’s to the
abdomen [2,3].
Effective policies on safety should be developed based
on evidence of local research and not on adapted models.
This study presents the current study of PAT characteris-
tics to highlight areas that require attention and proffer
solutions for prevention.
2. Patients and Methods
Pre-hospital interventions are not in place in our setting
as there are no ambulance/paramedic services. There is
no organized trauma team at reception yet, doctors and
nurses trained in accident and emergency receive the
injured at the reception bay. Primary survey/resuscitation
is carried out; thereafter the patients are referred to the
surgical unit on call based on the specialty/specialties
required.
The first on call is the registrar, followed by the senior
registrar (mostly pre-fellowship) and the consultant sur-
geon. Anesthesiology is organized in a similar pattern.
There is a theatre dedicated for emergencies and a three
bed intensive care unit.

Penetrating Abdominal Trauma: Experience in a Teaching Hospital, Calabar, Southern Nigeria 427
Patients admitted in the UCTH, Calabar with PAT
from January 2008 to December 2010 were prospectively
studied based on a questionnaire. This included bio-
graphic data, mechanism and circumstance of injuries,
injured organs, duration of admission, as well as associ-
ated injuries. Others included management and outcome.
Patients were categorized into two groups: operative
(laparotomy) and non-operative management (NOM).
The latter group is defined as patients with PAT without
peritonitis, heamodynamic stability without high spinal
cord or severe head injury. The policy of selective NOM
requires serial physical abdominal examination to rule
out hemorrhage and peritonitis. Failed NOM was defined
as patient who ultimately requires surgical exploration.
The total number of patients with PAT was compared
with total number of emergencies, traumatic injuries and
abdominal trauma seen during the same period. This was
also compared with an earlier study of PAT (2005-2007).
3. Results
During the study period of 3 years (2008 -201 0), a total of
12,083 patients presented to the accident and emergency
department of the University of Calabar Teaching Hos-
pital, Calabar. In the same period, 4942 (41%) trauma
patients were seen, of this, 48 (1%) suffered abdominal
injury: PAT 29 (60%) and BAT (19 (40%). In the previ-
ous 3 years of this prosp ective study (2005-2007), th e 79
abdominal trauma patients seen accounted for 4.8% of
trauma cases: PAT 39 (49%) and BAT 40 (51%).
The ages of the patients (28 male, 1 female) ranged
from 3 - 62 years (mean 28.1 years). During the 1st dec-
ade, the three children recorded suffered injuries due to
falls, the frequency increased to a peak in the 3rd decade
due to violent activities (stab, machete and gunshot inju-
ries). There was a decline from the 4th to the 7th decades,
Figure 1. Four patients in the 5th - 7th decades suffered
1 10 20 30 40 50 60 70
Age range (years)
11 -
10 -
9 -
8 -
7 -
6 -
5 -
4 -
3
2
1
No.
Age range: 3 - 6 years, (means 28.1year s) .
Figure 1. Age distribution.
gunshot injuries from robbers.
Table 1 shows the distribution of the type of injury.
Gunshot wounds were the commonest injury that in-
volved 11 (38.0%) patients. This compares with the pre-
vious study (2005-2007), GSW afflicted 15 (38.5%) pa-
tients, Stab wound ranked second 8 (27.6%), and this
showed a contrast with the previous study (2005-2007)
that recorded 18 (46.1%) patients. Others were machete
cut 4 (13.8%), falls and road traffic accident 3 (10.3%)
each. Violent crime (stab wound, machete cut, GSW)
were recorded in 23 (79.4%) patients while 2005-2007
showed 33 (84.6%) patients. The only female sustained
stab wound. The offending agents in stab wounds were
broken bottles and knives. The circumstances of GSW
were attacks by robbers and from police. The 3 children
recorded in this study fell on sharp objects (broken bot-
tles, sharp stick).
The commonest organ injury was perforation of the
small intestine 12 (37.5%) while evisceration of omen-
tum/small intestine ranked second 9 (28%), Figures 2
and 3. Others were perforation of the stomach 3 (9.4%),
spleen 3 (9.4%). Two (6.3%) patients each suffered inju-
ries to the mesentery/colon and a patient (3.1%) with
renal injury, Table 2. The commonest region with asso-
ciated injuries was the chest 3 (37.5%), Table 2.
Table 1. Type of injury .
Type of injury No. (%)
(2008-2010) No. (%) (2005-2007)
Stab injury 8 (27.6) 18 (46.1)
Machete cut 4 (13.8) -
Gunshot 11 (38.0) 15 (38.5)
Fall 3 (10.3) 1 (2.6)
Road traffic accident 3 (10.3) 2 (5.1)
Work related-cow horn
injury/shrapnel - 2 (5.1)
Criminal abortion (impale ment Inju ry) - 1 (2.6)
29 (100) 39 (100)
*Violent crime (Stab injury , machete cut, gunshot): 23 (79.4), 33 (84.6).
Figure 2. Clinical photograph—showing prolapsed small
intestine (stab wound).

Penetrating Abdominal Trauma: Experience in a Teaching Hospital, Calabar, Southern Nigeria
428
4. Discussion The patients were categorized into two groups for
management: operative (laparotomy) 25 (86.2%) and
non-operative 4 (13.8%). In the latter, the 4 male p atients
(stab wounds) whose ages ranged from 18 - 27 years
(mean 23.5 years) were managed with satisfactory
(wounds healed) outcomes. In the laparotomy group (25)
patients: one had a negative laparotomy while the out-
comes in 21 were satisfactory. The morbidity and mor-
tality profile is sho wn in Table 3. The dur ation of ad mis-
sion ranged from 2 - 19 days (mean 10.5 days). Two
(6.9%) patients who suffered stab injuries developed
surgical site infection (SSI), this was responsible for in-
creased duration of admission. Three (10.3%) patients
inflicted with gunshot injuries that resulted in colonic,
splenic/renal injuries had fatal outcome, Table 3.
Despite the decline in the number of PAT patients when
compared to our previous study [3], PAT now accounts
for 60% of abdominal trauma probably due to a decline
in BAT cases consequent upon the ban on motorcycle
use in Calabar. Osime and Oludiran in Benin, Southern
Nigeria [1] reported 34 cases of PAT in 10 years; this is
lower when compared to our report. In another report
from southwest Nigeria, Ayode et al. [9] reported BAT
79.2%, PAT 20.8% in keeping with our previous report
[3]. However, penetrating abdominal injuries appear to
be on the increase in Nigeria [8,10]. This trend has also
been observed worldwide possibly due to increase in
interpersonal violence throughout the world [11,12]. In
Kano, a populated urban area in Northern Nigeria, Edino
ST [13] reported PAT 53.7%, BAT 46.3% in keeping
with our recent experience.
Males constitute the great majority of patients with
penetrating trauma injuries across the United States, ap-
proximately 90% of patients with penetrating trauma are
male [2]. This compares with our finding (96.6%), Osime
and Oludiran reported 88.2% [1]. They constitute an ac-
tive aggressive segment of the population and more often
involved in acts of violence [3]. This is aggravated by the
high level of unemployment .
Osime and Oludiran showed that 21 - 30 year age
group was the most vulnerable (41.2%) [1], Navsaria et
al. mean age of 29.5 years [14]. Males in this age group
Figure 3. clinical photograph-showing prolapsed omentum
(gunshot wound).
Table 2. Organ/Associated injury.
Injured organ No. (%) Associated injury No. (%) (Region)
Evisceration of oment um/intestine 9 (28) Head (laceration) 2 ( 25.0)
Stomach 3 (9.4) Chest (laceration/haemothorax/pneumothorax) 3 (37.5)
Spleen 3 (9.4) Upper lim b (lace ration) 2 (25)
Small intestine (perforation) 12 (37.5) Lower limb (pellets/punctures) 1 (12.5)
Mesentery 2 (6.3)
Descending/sigmoid colo n 2 (6.3)
Renal 1 (3.1)
32 (100) 8 (100)
*1 patient had negative laparotomy; *3 patients had multiple organ injuries (gunshot).
Table 3. Morbidity/Mortality
S/No. Type of injury Age (years)Sex Finding at operation Treatment Outcome/duration
of admission
1. Gunshot 38 M Splenic/renal injury *Splenectomy
*Left partial neph r e c t omy Fatal (Shock)/1 d a y
2. Gunshot 17 M Perforated descending colonColostomy Fatal (Shock)/2 days
3. Gunshot 27 M Perforated sigmoid colon Resection/anastomosis Fatal (Shock)/2 days
4. Stab injury 30 M
*Moderate haemoperi-tonium
*Jejunal perforation
*Omental injury
*Closure of perforation
*Partial omentectomy
*Chest infection
*Surgical site infection
(SSI)/19 days
5. Stab injury 20 M
*Perforation of Ileum
*Pneumothorax
*Closure of perforation
*Closed thoracostomy tube drainage (CTTD) SSI/14 days
Mortality—10.3%; SSI—6.9%.

Penetrating Abdominal Trauma: Experience in a Teaching Hospital, Calabar, Southern Nigeria 429
generally are more aggressive in demonstrating resis-
tance to perceived threat when compared to the very
young and elderly [2,4]. This collaborates with our find-
ing, Figure 1 (mean 28 .1 years). It is rather distu rbing as
this age group constitutes the productive segment of the
society and this impact negatively on the economy. Chil-
dren in the first decade fell on sharp objects, proper care
of children is recommended as this inju ry is avo idab le.
Penetrating abdominal trauma may result from firearm,
knives, broken glass pieces, 80% of penetrating injuries
are due to firearm and 20% due to stab wound [15]. Our
current experience revealed a peculiar pattern in the dis-
tribution of etiology, gunshot (38%) ranked first fol-
lowed by stab injury (27%) while machete cut (13.8%)
was third, Table 1. Osime and Oludiran in Nigeria re-
ported gunshot injuries as constituting 64.7 % of cases [1].
When co mpar ed to our pr eviou s stud y [3], Ta ble 1, there
was a slight decline in GSW, a remarkable decrease in
stab wounds. Efforts to sustain the downward trend by
education against violent behavior would result in further
decline in violent injuries. Perhap s, the decline may have
been due to some patients presenting to other facilities in
order to hide their identity and evade prosecution. Ma-
chete, a common farm implement has become an of-
fending agent in our setting. Youths in the society move
about with machete hidden under their clothing’s [16].
Appropriate legislation and enforcement against the use
of this weapon as offending agent is recommended. This
is in addition to curbing illegal acquisition of firearms
and other offending weapons, including strategies for
peaceful co-existence and addressing issue of youth un-
employment.
The commonest organ injury was perforation of the
small intestine, while evisceration of omentum/small
intestine ranked second. Other studies attest to this [9,
13,17]. This is not surprising as the small intestine occu-
pies a large area of the abdominal cavity. Stab wounds
are caused by penetration of the abdominal wall by sharp
object. This type of wound generally has a more predict-
able pattern of organ injury. However, occult injuries can
be overlooked resulting in devastatin g complications [2].
Some studies have advocated adoption of conservative
management for penetrating abdominal injury especially
when it is due to stab injury [18]. In deed some patients
with stab injuries were successfully managed under the
non-operative group with the attendant advantage of re-
duction in the number of laparotomy with its complica-
tions. Evisceratio n should continue to prompt operational
intervention but exception can be made to a select few
patients with omentum evisceration with benign ab-
dominal findings [19,20]. Some of our patients attest to
this.
Laparotomy for gunshot injuries in patients with se-
vere injuries that resulted in shock was responsible for
the fatal outcomes in our patients; splenectomy for shat-
tered spleen (Type 1V) and renal injury, left colonic in-
juries (perforated descending and sigmoid colon). This is
not surprising as the management of abdominal trauma
hinges on the prevention of shock and infection (perito-
nitis), these when present, result in poor prog nosis. In ou r
setting where there is no pre-hospital treatment, no am-
bulance service, and sometimes-inadequate response to
resuscitation and timely surgery, these factors affect
negatively on the outcome.
Bowel injuries are a leading cause of morbidity and
mortality following trauma [5]. The colon and small in-
testine were the most commonly injured organs and had
the most postoperative complications [21]. In deed all
our patients with fatal outcomes and surgical site infec-
tion suffered bowel injuries. We recorded 10.3% mortal-
ity, this may be due to the fact that most severely inju red
die prior to hospitalization as there is no pre-h o spital care
in our setting. The average mortality rate for all patients
with PAT is approximately 5% in most level 1 trauma
centers [2], Van Brussel and Van Hee reported 8.8% [18].
Shock was responsible for the death in all the patients
with fatal outcome. Death from refractory hemorrhagic
shock or exsanguinations in the first 24 hours remains the
most common cause of mortality [2].
In summary, PAT accounts for 60% of abdominal
trauma. Males mainly in the third decade constitute the
great majority of patients with PAT. Machete cut was
peculiar in out setting and ranked third after gun shot and
stab injuries that ranked first and second respectively.
Bowel injuries were common injuries and accounted for
morbidity and mortality. Non-operative management is
safe for omental prolapse from stab injury with benign
abdominal findings.
5. Conclusion
Key areas that require attention have been highlighted.
No single solution exists for every hospital or community,
individualization based on research findings is the key.
Paramount importance must be placed on patient, family,
community and support groups with interest in education
which should be proactive in reduction of violent injury
in our society. Revamping the ailing economy and gain-
ful employment for youths remain as paramount areas
that require prompt, dedicated and sustained intervention
for reduction in violent crimes.
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