Visceral injuries: systematic review

Summary

Abdominal injuries are a significant cause of morbidity and mortality amongst abused children. The challenge for clinicians is to recognise that such injuries have occurred, as many symptoms are non-specific and occur predominantly in pre-school children. Whilst almost every organ of the body has been reported as having been injured, the literature in this review predominantly addresses abdominal injuries.

This systematic review has been updated and now evaluates the scientific literature published until September 2021. It includes visceral injuries that are not included in the other systematic reviews, apart from ear, nose and throat injuries, which are the subject of a separate review.

There has been limited evidence identified since the 2018 update and so the key findings remain unchanged. A single case series has been included in the 2021 update which aimed to assess the use of screening urinalysis to detect abdominal injuries in suspected physical abuse.

The review aims to answer two clinical questions:

• • What are the features of visceral injuries occurring as a consequence of physical abuse?
  • What is the value of non-radiological investigations in detecting abusive abdominal injury?

Key findings:

• • Many abdominal injuries, in particular hepatic injury, may be clinically occult and thus active consideration of blunt abdominal injury in children with suspected abuse is necessary
  • Abdominal injuries such as transection or laceration of the third/fourth part of the duodenum in children aged less than five years, particularly those less than two years old, who have not experienced a motor vehicle collision should prompt specific child protection investigations
  • In the child sustaining head injury or who is unconscious as a consequence of their abusive injuries, abdominal injuries must be considered during their investigation
  • Many children sustaining abusive abdominal injury have evidence that there has been repeated blunt abdominal injury, although they have not come to attention with previous injuries. Thus, non-specific symptoms in young children with suspected abuse should prompt abdominal investigations
  • While a positive serology test may warrant further investigation, those with negative serology may also have significant intra-abdominal injury
  • Infants less than 6 months of age with bruising but no other symptoms or signs of injury may still have occult abdominal injury
  • Absence of bruising does not preclude the presence of significant abdominal injury as up to 80% of cases may have no bruising present