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Gastric injuries
The stomach is a relatively thick-walled, well-vascularized organ that is variably positioned in the peritoneal cavity. Although partially protected by the lower rib cage, its size and location put the stomach at risk for injury, particularly with injury from penetrating trauma to the abdomen or lower chest.
The generous blood supply to the stomach includes: (1) the left gastric artery, a branch of the celiac axis; (2) the right gastric artery, a branch of the common hepatic artery; (3) the right gastroepiploic artery, a branch of the gastroduodenal artery; (4) the left gastroepiploic artery, a branch of the splenic artery; and (5) the short gastric arteries, which also arise from the splenic artery. Because of the plentiful blood supply, gastric injuries can cause significant bleeding and require precise hemostasis in their repair. However, the excellent blood supply to the stomach contributes to the good results of the surgical repair of most gastric injuries in even the worst clinical circumstances.
The normal stomach is relatively free of bacteria and other microorganisms; however, typical oral flora and even Candida may be found. Factors that may impact the gastric flora include pharmacologic acid suppression and a postprandial state.
The stomach has a number of important anatomic relationships, including the diaphragm, liver, spleen, pancreas, and transverse colon and mesocolon. Concomitant injuries to these adjacent structures often dictate the priority of management of the ultimate outcome for both blunt and penetrating gastric trauma.
Incidence
Gastric injuries usually result from penetrating trauma and occur in approximately 20% of gunshot wounds and 10% of stab wounds. Blunt gastric trauma is much less common. In the American Association for the Surgery of Trauma (East) multi-institutional study on hollow viscus injury, the prevalence of blunt gastric rupture was 0.06% in patients undergoing evaluation for blunt abdominal trauma and 2.1% of all patients found to have hollow viscus injury.
Mechanism of injury
The stomach is at risk for injury following stab wounds to the left thoracoabdominal region of the body. A single perforation occurs in over 50% of these cases. However, injury to adjacent organs is common. Gunshot wounds result in two or more gastric wounds in 90% of cases. Although often associated with some surrounding tissue damage to the stomach, this is usually only significant with high wounds at close range (<15 feet) and are often associated with massive destruction of the abdominal wall, stomach, and other intraabdominal organs.
Blunt injury to the stomach is most often the result of motor vehicle crashes or motor-pedestrian trauma. Less common causes include falls, assaults, and improperly performed cardiopulmonary resuscitation. Blunt gastric injuries include linear lacerations and complete gastric rupture. Postulated mechanisms for blunt gastric injury include sudden increases in intraluminal pressure resulting in a balloon-bursting type of phenomenon of a full stomach, compression against the spine (seat belt injury), or deceleration injury with shearing forces resulting in a laceration of the anterior stomach wall.
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