Visceral injury including abdominal injury

VFPMS Guideline: Forensic investigation for visceral injury

Visceral injuries are injuries to all internal organs. Abdominal injuries are described more frequently than thoracic injuries. Abdominal injuries in young children in the absence of a history of significant trauma are rare. Many abusive abdominal injuries, in particular hepatic lesions, are occult. Remembering to search for possible visceral trauma in the context of investigations for physical abuse is important.

Key points:

Abdominal injuries are a significant cause of morbidity and mortality in abused children.
Visceral injuries may be occult and their diagnosis delayed because injury to internal organs was initially not suspected.
Almost every organ in the body has been reported as having been injured through child abuse.
Injury to the small intestine in young children (less than 5years-old and particularly in those less than 2years-old) who have not experienced motor vehicle accidents warrants serious consideration for abuse.
In infants with suspected Abusive Head Trauma, abdominal injuries should be considered.

Investigations:

When significant physical abuse is suspected (in any form), VFPMS recommends laboratory screening for occult abdominal injury

Pancreatic enzymes (including amylase and lipase)
Liver Function Tests
Urine dipstick (for haematuria)
FBE (for occult blood loss)
Fibrinogen

Consideration should be given to radiologic investigations

Abdominal X-rays (including erect and supine) and ultrasound may be considered.

Abdominal CT Scan with contrast is the investigation of choice that should be obtained if the following concerns are present:

Possible paralytic ileus (absent/hypoactive bowel sounds)
Possible intra-abdominal haemorrhage
Significantly abnormal laboratory results (for example AST or ALT >80IU/L)
≥2 abnormal abdominal laboratory results
Concerning physical examination findings (including abdominal bruising, distension or tenderness)

Useful resources and articles:

The Royal College of Paediatrics and Child Health’s review (UK, 2018) Child Protection Evidence on Visceral Injury evaluates the literature on visceral injuries and provides data on the following questions: What are the features of visceral injuries occurring as a consequence of physical abuse? What is the value of non-radiological investigation in detecting abusive abdominal injury?
Trout AT et al.’s article (2010) Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use? discusses pre-test probabilities of CT Scan in the context of suspected physical abuse
Maguire SA et al.’s article (2013) A systematic review of abusive visceral injuries in childhood – Their range and recognition presents the data on visceral injuries in the context of physical abuse and calls for clinical vigilance.
Lane WG et al.’s article (2009) Screening for Occult Abdominal Trauma in Children with Suspected Physical Abuse presents a strong argument in favour of screening for abdominal injury in abused children

The Royal Children's Hospital Melbourne

Victorian Forensic Paediatric Medical Service

Visceral injury including abdominal injury

VFPMS Guideline: Forensic investigation for visceral injury

Key points:

Investigations:

Useful resources and articles: