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Burns of the upper gastrointestinal tract, caused by acids, alkalis, drugs or heat may lead to stenoses, some of them severe, to perforations, to inanition and to the patient's death. The type of damage differs among the various groups of noxious agents. First aid at home is almost non existent. On admission every effort must be made to identify the ingested material. Parenteral fluids and antibiotics are used and in some patients nutritional support will be required. The extent of the damage must be evaluated endoscopically. Strictures, caused by intramuscular collagen formation, could possibly be prevented by steroid therapy. If stenoses occur, these must be cautiously dilated. A late complication of oesophageal burns is carcinoma. There appears to be a relation between this grave complication and the use of very hot beverages in certain countries where oesophageal cancer is common. Upper gastrointestinal burns are similar to skin burns, however, their dangers may be greater as they occur in a pipe-like structure and very close to vital viscera.

Injuries to the upper gastrointestinal tract occurring over a 30-year period in a geographically well defined region were analyzed. The incidence was low in comparison with other abdominal injuries, but duodenal and pancreatic injuries were increasingly common in the study's last decade. The stomach injuries were mainly caused by penetrating trauma. The duodenal and pancreatic injuries most commonly resulted from road-traffic accidents. Two duodenal injuries were overlooked at the initial exploration, in which the duodenum was incompletely exposed. Anastomotic insufficiency occurred in one of the three patients who underwent duodenal resection. Most of the pancreatic injuries were contusions that could be managed with drainage. The pancreas was severely damaged in five patients, all of whom had multiple intra-abdominal injuries. Three of the five patients died before or during operation.

During the past 8 1/2 years, we have treated 34 adult patients admitted for ingestion of caustic materials. In 19 patients the injury was accidental, and in 15 patients ingestion was a suicide attempt. Ingested agents included hydrochloric acid in four patients, sulfuric acid in one patient, a strong alkali such as sodium hydroxide or Drano in 15 patients, liquid bleach in eight patients, detergents in four patients, and ammonia in two patients. Each patient underwent early fiberoptic endoscopic evaluation. The extent and severity of the injury varied according to the ingested agent. Seven patients who had second- or third-degree injury had surgery. One patient who ingested sulfuric acid required hemigastrectomy for pyloric stenosis. Two patients with Drano ingestion had necrosis of the stomach and required total gastrectomy. Five patients with strong alkali ingestion had esophageal strictures, and colonic interposition was performed on four of these patients. No patient who had ingested bleach, ammonia, or detergent required surgery. Panendoscopy after caustic ingestion can be performed safely and provides an accurate guide for therapy. The ingestion of strong acid or alkali may produce profound pathologic changes, which may require surgery for perforation or stricture. Bleach, detergent, and ammonia usually cause mild injuries that will respond with medical treatment.

A working familiarity with the management of common perioperative gastrointestinal complications is required for all general gynecologists. Thermal gastrointestinal injury requires resection of the damaged portion of bowel unless the injury involves only the bowel serosa and is less than 0.5 cm in diameter. Small intraoperative lacerations of the intestine can be closed primarily, whereas larger lacerations often require resection. Some degree of postoperative ileus may be expected, but prolonged ileus requires nasogastric suctioning while excluding bowel obstruction, peritonitis, or electrolyte imbalance. Small-bowel obstruction, most likely to be caused by postoperative adhesions, can often be treated successfully by gastrointestinal intubation. Steps required in the initial management of an enterocutaneous fistula include institution of parenteral nutritional supplementation and antibiotics, skin protection, and investigative studies of the fistula. Preventive measures may be used at the time of any surgical procedure to reduce the incidence of many of these complications.

A review of records from admission to the trauma center at Yale-New Haven Hospital for a five year period (July 1981 through June 1986) revealed 41 blunt hollow viscus injuries in 31 patients. Organs injured included small intestine (18), large intestine (14), duodenum (6), stomach (2), and gall bladder (1). The most accurate predictors of blunt hollow viscus injury were peritoneal lavage (91%, n = 14) and abdominal tenderness (50%). Seventeen patients underwent early celiotomy with morbidity and mortality rates of 16% each. Nonetheless, 13 patients had delay in diagnosis with substantially higher morbidity (46%) and mortality (31%). Blunt hollow viscus injuries are uncommon, are difficult to diagnose, and can lead to major morbidity and mortality when diagnosis is delayed.

Clinical-anatomical correlations are drawn for 155 cases of esophageal injuries related to instrumental investigations. These injuries involved a lethal outcome in 21% of cases. Relevant pathology is referred to as iatrogenic. The analysis suggests a relationship between an early diagnosis and outcome. Morphological characteristics are presented for esophageal injuries and associated complications. Considered are iatrogenic damage to the gastric wall due to glue application, sequelae of endoscopic choledochotomies, laparoscopies, etc. A rare complication of small intestinal intubation with resultant invagination is recorded. The complications are assessed morphologically, their outcomes are listed. The authors emphasize the significance of the clinico-morphologic analysis of each individual pathology for formulating postmortem diagnosis and cause of death.

During the last 10 years 0.45% of all our patients were operated on because of blunt (92) or penetrating (22) abdominal trauma. In the acute phase, diagnosis can be made on clinical symptoms alone. Of the early diagnostic procedures, peritoneal lavage is most reliable. Laparoscopy, ultrasonography, computed tomography, and arteriography are procedures used later, but only when the patient's circulation is stable. The most frequent injury encountered is splenic rupture, followed by rupture of the liver and gastrointestinal tract. When one single organ is injured, lethality is under 10% and grows to more than 30% when several organs are injured.

Child maltreatment continues to be one of the most common and most difficult problems seen in the emergency room. An early estimate indicated that up to 10% of children under age 6 seen in emergency departments have some form of nonaccidental injury. Recent data suggest that approximately 1% of the child population are victims of maltreatment each year. Many of these cases involve only subtle signs and have great potential to pass undetected. This article provides a review of the various forms of maltreatment, with emphasis on the key points involved in the history, physical examination, and management. The protocol for evaluating maltreatment from the North Carolina Memorial Hospital is presented. This framework will aid the physician in the crucial first step of identifying maltreatment, which, along with diligent follow-up and the assistance of the available social services, offers the best hope for further prevention.

Seventeen patients who ingested liquid caustics were reviewed for location, extent, severity, and outcome of the mucosal injury. Although many complained of glossopharyngeal pains and dysphagia (12 patients), and most had some oral mucosal burns (15 patients), the absence of severe oral burns or pharyngoesophageal symptoms did not exclude esophageal or gastric injury as determined by endoscopy. The location of the most severe mucosal injury was unpredictable by symptoms alone; seven of the 17 patients demonstrated gastric mucosal injury greater than esophageal. One patient died of extensive esophageal, gastric, and duodenal injury; esophageal strictures developed in three patients. Caustic ingestion is a serious medical condition whose severity can best be gauged by endoscopic findings and not by patient symptoms alone. Outcome is variable, ranging from an asymptomatic state to stricture formation or even death.

Extent and seriousness of an abdominal trauma can be defined in 4 clinical stages. Clinical stage IV is characterized by acute bleeding to death caused by injuries of the aorta, V. cava, liver- or hepatic veins. Clinical stage III includes haemorrhage caused by liver or spleen injury. The haemorrhage of the liver which cannot be controlled surgically indicates hepatic artery ligation. In clinical stage II injuries of the duodenum, pancreas and gastrointestinal tract are predominant and necessitate diagnostic procedures. Symptoms of shock prevail in clinical stage I frequently, there are no organ injuries. The midline abdominal incision with possible extension to median sternotomy or right thoracotomy remains the optimal approach.

A single case of operatively proven spontaneous rupture of a normal stomach secondary to diving barotrauma is reported. The rupture was linear and located along the lesser curvature, as described most commonly in adults. Possible mechanisms to explain the closed loop obstruction required to produce this phenomenon are the swallowing of water and filling of the stomach with air, while trapped under water, at a depth of 27 meters. To the best of the authors' knowledge this case represents the first report of gastric rupture secondary to SCUBA (self-contained underwater breathing apparatus) diving. The presence of a normal abdominal examination by an experienced observed while compressed in the chamber does not preclude the diagnosis of a perforated viscus.

Blast injuries cause specific lesions with which the radiologist should be familiar. The mechanism of injury and the pathophysiology of this form of trauma are discussed. The clinical effects as well as the radiologic observations in various organs are presented. Most dramatic effects are observed in the thorax.

From 1979 to 1982, an estimated 8,176 toothpick-related injuries occurred yearly (3.6 per 100,000 population per year). The rate of injury was greatest among children 5 to 14 years old, but children younger than 5 years had a rate of injury to the eyeball and ear more than 20 times greater than that of other persons. Since young children appear to be at greatest risk, toothpicks should be kept out of their reach.

The clinical use of Hexabrix (May and Baker) was started about 3.5 years ago for the radiological evaluation of patients in whom the possibility of leakage of contrast medium outside the upper gastrointestinal tract, particularly the oesophagus, was anticipated. The majority (greater than 70%) of the patients were in their early post-operative period. No adverse reactions because of the use of Hexabrix were encountered.

Any wound that penetrates the abdomen may involve the gastrointestinal tract whether controlled for a specific operation of diagnostic procedure or uncontrolled when secondary to blunt or penetrating trauma. The first important consideration is the prevention of complications. The choice of incisions, the managment of the contaminated peritoneal cavity, intestinal fistulas and specific bowel injuries and the importan differences in the treatment of injuries to small intestine versus to large intestine and rectum be considered. Bowel viability must also be determined.

Widespread acceptance of Limulus Amoebocyte Lysate testing in clinical situations has been elusive. The results obtained in this series of 38 patients seem to support the contention that the amylase-endotoxin complex can be of value in detecting rapidly and with reasonable sensitivity the presence of pancreatic injury and gastrointestinal perforations. A corrected WBC count appears to add diagnostic possibilities to the technique. Despite the promising evidence detailed in this paper, further studies are required to establish the true sensitivity/specificity of the test. Its validity and utility could be assessed rapidly if traumatologists who routinely perform lavage would utilize this method and report their findings.

Terrorist bombings remain a not uncommon problem. Most of the victims suffering primary blast injury die, if not from the blast then from secondary missile injuries, while most of the survivors have more or less serious secondary injuries alone. A small percentage have either pure blast injury or secondary injuries complicated by blast phenomena. It is important to recognize this group and treat it appropriately.

Injuries to the pancreas and gastrointestinal tract following blunt abdominal trauma continue to be a significant cause of morbidity and mortality in the pediatric age group. Optimal treatment of these injuries is frequently hampered by considerable delays in diagnosis. Factors contributing to these delays include the location of much of the duodenum and the pancreas in the retroperitoneum resulting in an absence of initial symptoms and signs, the often trivial nature of some of the responsible blunt traumatic accidents, inappropriate child-parent or child-physician communication, failure to achieve a meaningful physical examination in uncooperative or unconscious patients, and false negative paracentesis. Eighty per cent of these injuries occurred in boys. Eleven of 16 patients with pancreatic trauma had pseudocysts. A persistently elevated serum amylase level was invariably noted and epigastric mass was palpable in eight patients. Significant delays in diagnosis were prevalent and pseudocysts was misdiagnosed as appendicitis in three cases. Internal drainage by cystgastrostomy or cystjejunostomy was effective operative treatment. In instances of acute pancreatic injuries, sump drains, gastrostomy, cholecystostomy, and total parenteral hyperalimentation were useful therapeutic adjuncts. There was one death for a 6.2 per cent mortality rate. Forty patients had gastrointestinal injuries involving the duodenum in 17, jejunum in 14, ileum in seven, and stomach in two. Perforations occured in 65 per cent of cases, obstructing hematomas in 30 per cent, and mesenteric avulsions in 5 per cent. Associated injuries were observed in 15 patients (37.5 per cent). Pain and tenderness were the only consistent findings. Upper gastrointestinal contrast studies were diagnostic of duodenal hematomas. Eighty per cent of perforations were managed by simple closures and 20 per cent by resection and anastomosis. Obstructing hematomas unassociated with other injuries may be expected to resolve without requiring operation in 50 per cent of patients managed conservatively. Complications occurred in 35 per cent of patients and the mortality rate was 12.5 per cent (five deaths).

Gastrointestinal injuries were noted in 53 children. Blunt trauma was responsible for 51 cases, and penetrating wounds in two. There were 42 boys and 11 girls (mean age, 8.1 years). The site of injury was the stomach (2), duodenum (17), jejunum (19), and ileum (15). Types of injury included two gastric perforations, 16 duodenal hematomas, one duodenal laceration, 27 jejunoileal perforations, five mesenteric avulsions, one abdominal wall laceration and evisceration, and one entrapment necrosis between lumbar vertebrae. Diagnosis was accomplished by observing free air on x-ray, with contrast (duodenal haematoma), computed tomography, and frequent examination (noting peritoneal irritation). Thirty-four associated injuries occurred in 21 patients (40%) including the liver (6), pancreas (6), skeletal injury (6), head trauma (5), diaphragm (4), lung (3), spleen (2), and kidney (2). Nine of 16 duodenal hematomas resolved non-operatively, while seven were evacuated during other procedures. Twenty-three of 30 perforations had simple closure, while seven (jejunoileal) were resected. Mesenteric avulsions required resection in five cases--the eviscerated bowel was replaced and the entrapped bowel resected. Twenty complications occurred in 13 patients, including atelectases (6), pseudocyst (5), sepsis (4), wound infection (2), subhepatic abscess (1), subglottic stenosis (1), and short bowel syndrome (1). One infant (aged 2 months) with a duodenal laceration died of head injuries (1/53 = 1.8% mortality). Prompt recognition and appropriate treatment result in improved survival.

The mandatory use of seatbelts has become commonplace in Canada, and such legislation was adopted by the province of British Columbia in 1977. This has provided us with an opportunity to study the effects of seatbelt restraints on accident victims, particularly concerning abdominal injuries. Five hundred sixty-two patient charts were reviewed during a 3-year period. Documented use of seatbelts was found in 126 cases. Thirty-six of these patients underwent laparotomy and form the basis of this study. Compared with previously reported figures for blunt abdominal trauma, there was a high incidence of gastrointestinal injuries (67 percent). In addition, associated lumbar spine injuries were found in a large proportion of patients (19 percent, p less than 0.005). We found an increased risk of spinal injury in patients wearing a lap versus a three-point belt.

Two cases with roentgenologic findings of extravasation of contrast medium into the stomach and colon following lymphangiography are presented. One is clinically diagnosed as primary intestinal lymphangiectasia; the other as retroperitoneal spread from uterine cancer. The significance of lymphangiography in gastrointestinal or retroperitoneal disorders is discussed.

Cholecystectomy is the most common type of abdominal surgery performed among adult patients. Almost 500,000 biliary tract operations are done in the United States each year for treatment of gallstones and associated biliary disorders. Complications of local or systemic nature develop in 10 to 15% of these cases, and radiological methods frequently play a crucial role in their diagnosis and management. This article presents a comprehensive review of the clinical and radiological features of the spectrum of complications encountered after cholecystectomy and bile duct exploration.

The ultrastructure of the smooth muscle tissue was studied in the posterior vena cava in rats after the disturbance of blood outflow, in the stomach following resection of half of its fundus and cecum after constriction of its ascending limb. "Activation" of the smooth muscle was found to reflect the stage of the cell ultrastructure injury, and then the processes of intracellular regeneration. Analysis of the correlation between the DNP-synthesizing and the "activated" cells showed the latter to be of local origin, from the differentiated myocytes.