This article will discuss an evidence-based approach when evaluating a young child presenting with concern for abusive visceral trauma. The types of pediatric visceral injuries along with salient features will be described. Additionally, the approach to assessing these children with clinical data including laboratory screening tests and imaging modalities will be addressed. The pediatric clinician will understand the importance of approaching this population with appropriate clinical vigilance while maintaining a comprehensive, objective, unbiased, evidence-based approach to the medical assessment of young children presenting with concern for child abuse where visceral trauma is a concern.
Key points
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Many visceral injuries in young children are clinically occult necessitating an evidence-based high index of suspicion in this high-risk population.
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The large majority of children presenting with significant intra-abdominal injury have no associated abdominal bruising.
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The discovery of a poorly explained traumatic injury in a young child, especially hollow organ perforations, should prompt a thorough assessment for nonaccidental trauma.
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When evaluating for non-accidental trauma, negative screening laboratory studies may not be and imaging with gold standard intravenous abdominal/pelvic computed tomography may be warranted.
Introduction
Nearly every internal organ of the body has been reported as injured in abused children. Abusive trauma involving intra-abdominal organs, in particular, is a known significant cause of morbidity and mortality in young children. It is second only to abusive head trauma as a leading cause of mortality in children who are abused. While skin injuries and fractures occur more frequently and, in many cases, are more readily detected in physically abused children, pediatric clinicians who are knowledgeable about the variations in presentation, mechanisms of injury, and evidence-based guidelines in the medical evaluation of visceral injuries in young children where physical abuse is a concern, will be best positioned to accurately and promptly diagnose and treat this vulnerable population. Prompt recognition of abusive visceral trauma requires an awareness and concern for potentially serious underlying and unseen injuries, with simultaneous and consistent use of evidence-based protocols in order to optimize detection and decrease bias and health disparities that can lead to a broad spectrum of adverse consequences for children. Fig. 1 depicts visceral organs that will be reviewed in this article.
Epidemiology
In 2024, The US Department of Health and Human Services reported that over 558,000 children were substantiated victims of child abuse and neglect, a rate of 7.7 per 1000, with the highest rates in children aged less than 1 year. Physical abuse made up 17% of the substantiated cases of child maltreatment. Child abuse fatality, the most devastating consequence of child maltreatment, was estimated at a rate of 2.73 per 100,000 in this report, again with the youngest children being the most vulnerable and children aged less than 1 year representing just under 45% of the estimated 1990 fatalities.
The incidence of pediatric abusive abdominal trauma in the United States was first addressed by Lane and colleagues in their 2012 study evaluating the frequency and rate of hospitalizations for abdominal trauma utilizing the 2003 and 2006 Kids’ Inpatient Database. Prior to their study, US reports about the occurrence of abusive abdominal injury in physically abused children ranged from 0.5% to 11%. One UK study looking at hospitalized abused children aged 0 to 14 years found an incidence of abusive abdominal injury of 0.90 cases per 1 million children per year in all children in the study and 2.33 cases per 1 million children per year in children less than 5 years. Utilizing a stronger sample population than prior US studies, auditing all child abuse hospitalizations in 2003 and 2006, Lane’s study reported that 3.8% and 4.3% of children aged 9 years and younger involved abusive abdominal trauma in 2003 and 2006, respectively. A higher percentage of abusive abdominal trauma was seen in children hospitalized for abdominal injuries at near 5% and 6% in those same years ; even higher for younger children aged between 1 and 2 years at 11% and 18% in 2003 and 2006, respectively; and near 28% in 2003 and 25% in 2006 for the youngest children aged less than 1 year. In comparison to the UK study, the US hospitalization rate for abusive abdominal trauma is estimated at 15 per 1 million children aged less than 1 year and 10 per 1 million children aged 1 to 3 years. A recent multicenter cross-sectional study of children aged less than 10 years who were evaluated by a child abuse pediatrician for concerns of physical abuse demonstrated abdominal injuries in 2.1%.
Over the years, studies have reported mortality rates in children from abusive abdominal trauma ranging from as low as 8.8% in abused children with abdominal injuries only up to 50%. , Lower mortality rates (18%) have been reported in abused children with visceral injuries in the presence of other physical injuries, specifically traumatic intracranial injuries. , In one 2011 retrospective study involving 84 abused children with abdominal injury and evaluated with computed tomography (CT) imaging, 16 (∼19%) children died, all of whom had accompanying intracranial injuries, and none as a result of their abdominal injuries even when surgical intervention was required. Lower mortality rates are credited, in part, to the increasing use of CT scan in the identification of intra-abdominal injuries and advances in medical care.
Intra-abdominal organ injuries associated with child physical abuse have been among the most commonly reported in literature. While some studies note that solid organ injuries are more commonly injured in both accidently injured and physically abused children, , Maguire and colleagues’ 2013 and the Royal College of Pediatrics and Child Health’s (RCPCH) , 2021 systematic review of childhood abusive visceral injuries noted that solid and hollow organ injuries were generally equally common. , Hollow organ injuries and pancreatic injuries have been reported more commonly in abused children. , , Child physical abuse was the suspected cause in 77% of hollow organ injuries and 66% of pancreatic injuries in a 2006 review of children aged less than 5 years who had blunt abdominal trauma not associated with a motor vehicle collision (MVC). Table 1 is taken from Henry and Lindberg’s Visceral Manifestations of Child Abuse: Child Abuse Medical Diagnosis and Management , and is inclusive of several research studies dating from 2005 to 2012 highlighting the frequency of different categories of intra-abdominal injuries comparing those found in all children versus those found in abused children. , , , ,
| Intra-abdominal Organ | % of Injuries Reported in all Children | % of Injuries Reported in Abused Children |
|---|---|---|
| Spleen | 47 | 9–10 |
| Liver | 33 | 49–64 |
| Kidney/adrenal gland | 17 | 19–20 |
| Pancreas | 3 | 7–20 |
| Hollow organ/mesentery | 18 | 12–50 |
Presentation
Children with abusive visceral injuries can present with a diverse range of symptoms, from clinically occult and essentially asymptomatic with nonspecific or no physical findings to clinically overt with obvious physical signs and symptoms of illness. The specific organ, type of injury, severity of injury, and time of presentation relative to injury all play a role in how a child may present. Pediatric clinicians will need to maintain a healthy index of suspicion in order to navigate which children require further evaluation when signs and symptoms of illness are subtle. They must also be knowledgeable about presentations that are more likely to be the result of abusive visceral injury versus accidental injury when historical details are either lacking or implausible for a child’s particular presentation. This is paramount to protect children from future injury and to help direct additional diagnostic evaluation.
Several strong comparative studies from 1988 to 2013 have evaluated characteristics associated with intra-abdominal injuries occurring from accidental injury versus abusive injury. , Features associated with abusive intra-abdominal injuries include the following:
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Abused children with intra-abdominal injuries are younger . , , , , More than half of abused children with intra-abdominal injuries were aged less than 3 years in one series with a mean age ranging from 2.5 to 3.7 years. , This is in contrast to children with accidental intra-abdominal injuries where the mean age was 7.6 to 10.3 years. ,
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Children aged less than 5 years very rarely sustain small bowel injuries from accidental falls . , , Gaines and colleagues found that all 8 of the children aged less than 4 years in their series who presented with duodenal injury were victims of physical abuse, most had additional traumatic injuries (eg, fractures, soft tissue injuries, and intracranial injury), and only one had a reported accidental trauma history involving a fall down 13 stairs. A prior 2000 study had already found no relationship with stair falls and intra-abdominal injury nor intestinal perforation in 600 and 300 cases, respectively. In another series, no child aged less than 5 years had a small bowel injury from a reported fall, and small bowel injuries were significantly more common in abused children.
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Injuries involving both the hollow and solid organs are more common in abused children . ,
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Abused children may have a delayed presentation to medical care relative to the time of injury . , In Ledbetter and colleagues’ series of 156 children, all with abusive intra-abdominal injuries had a delay in presentation defined as greater than 3 hours from injury versus 91% of children with accidental injuries, who presented to care within 3 hours. A later study by Woods and colleagues comparing high-velocity and low-velocity accidental injuries to abusive injuries, homed in on the precision of associating delayed presentation as an indicator of abuse. When considering a delayed presentation of greater than 12 hours with a higher severity of injury, they improved the specificity of delay to care as an indicator of abuse from 65% to 90%, with a modest positive predictive value (PPV)( improvement from 39% to 67%, where 3 out of 9 children with accidental injuries would have been considered abused. Delay to care in the accidental group included 2 children aged 4 and 5 years, with splenic lacerations from a jungle gym fall and bicycle handlebar impact, respectively; and one 4 year old child with a small bowel laceration from an impact fall onto a rock, highlighting the need for caution when considering delay in care as an indicator of abuse in pediatric intra-abdominal injuries, as there is evidence that some children with accidental trauma can have delayed presentations.
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Abused children are more likely to die of their injuries . Ledbetter and colleagues found an overall mortality rate of 24% in the 156 children aged less than 13 years with blunt abdominal trauma injuries, with a much higher mortality rate of 53% in abused children versus 23% in those who were accidently injured.
History, symptoms, and physical examination findings
Pediatric intra-abdominal injuries: Gathering a detailed history is an essential feature in the evaluation of suspected victims of physical abuse. Common to other types of child physical abuse, clear historical information from caregivers is either often not present, lacks detail, or is implausible in comparison to a child’s presentation. , Household falls (bed, couch, and stairs) and poor explanation or no explanation for presenting symptoms were frequently provided histories for abusive intra-abdominal injuries in one earlier study by Ledbetter and colleagues. Hilmes and colleagues found that less than half of the 84 abused preschool-aged children evaluated for intra-abdominal injury presented with a history of injury, which was most commonly a fall. There was no notable difference between those found to have intra-abdominal injury and those who did not.
S ymptoms associated with injury to abdominal viscera can be nonspecific with examples noted in Box 1 . , The presence of these symptoms should prompt the pediatric clinician to consider the possibility of intra-abdominal injury and help inform further evaluation.
Symptoms potentially indicative of abdominal organ injury
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Fussiness/irritability/inconsolable
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Increased somnolence/altered mental status
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Decreased activity level
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Poor feeding/appetite
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Nausea
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Vomiting (nonbilious or bilious)
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Abdominal pain
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Fever
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Constipation
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Bloody stools
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Hematuria
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Hematemesis
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Decreased urine output
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A complete and thorough physical examination in infants and children is another essential feature in the evaluation of potential physical abuse. Physical findings specific to intra-abdominal injuries include bruising to the abdomen/flank, abdominal distention, diminished or absent bowel sounds, and tenderness/pain to palpation. A 2009 prospective multicenter study evaluating children aged less than 5 years referred for subspecialty child abuse assessments found that the aforementioned findings had overall low sensitivity ranging from 37% to 52%, with overall high specificity ranging from 93% to 99%. Abdominal tenderness was the physical examination finding with the highest sensitivity and specificity in this cohort at 52% and 99%, respectively. Another later retrospective review of abused children of the same age group, though different in that they all had gold standard definitive testing with an abdominal CT identifying 35 out of 84 intra-abdominal injuries, found that the only physical findings associated with intra-abdominal injury were abdominal distention and abdominal bruising. This same study additionally noted a higher incidence in symptoms with more severe injury requiring surgical intervention, with some reporting presenting in hemodynamic shock with splenic injuries. , The pediatric clinician should also be aware that children with significant intra-abdominal injury may present with no obvious physical examination findings, as up to 80% of cases may have no bruising.
Other pediatric visceral injuries: Gathering history, assessing signs and symptoms of illness, and physical examination findings should be approached similarly as noted earlier. Some less commonly occurring abusive visceral injuries may be more difficult to diagnose without additional definitive imaging modalities, especially pharyngeal, esophageal, and other intrathoracic injuries. , ,
Pharyngeal and esophageal injuries may present with irritability, unusual cry, poor feeding, oral bleeding or blood-tinged sputum, drooling, difficulty swallowing, inspiratory stridor, respiratory distress, or subcutaneous emphysema with obvious swelling of the neck and chest.
Infants with underlying intrathoracic injury and associated rib fractures can present with nonspecific symptoms that can be easily confused with other nontraumatic illnesses, like reflux, constipation, or colic. Intrathoracic injuries have not been found to be present more commonly in young, abused children with rib fractures when compared to children with rib fractures from accidental injuries. Darling and colleagues found that abused children aged less than 3 years who had more rib fractures were less likely to have any associated intrathoracic injuries at 12.8%, which were mostly noted to be closely adjacent to the chest wall, versus the accidently injured children who had less rib fractures but were more likely to have intrathoracic injuries at 55.6%.
Signs and symptoms from abusive injuries to other visceral organs, like the bladder, lung, and heart may be obvious based on the severity of their presentation. Children may present with the discovery of other poorly explained traumatic injuries, renal failure, sepsis, flail chest (paradoxic movement in which the chest wall moves in with inspiration and out with expiration), worsening respiratory distress, cardiac failure, sudden death, and unexpected fatalities. ,
Mechanism of injury
Precise details regarding how a child is harmed resulting in abusive visceral injuries are rarely provided just as in other forms of physical abuse. Single or multiple episodes of blunt force, compressive forces from direct blows with fists, an object, kicking, being thrown against a hard surface, or being hurled with resultant rapid deceleration effects are all common causes of abusive intra-abdominal injury in young children. , , Young children are especially vulnerable to intra-abdominal organ injury because they have thin, less well-developed abdominal muscles and more pliable, flexible ribs allowing for the propagation of forces to underlying organs. Hollow organs like the duodenum and proximal duodenum are predisposed to injury from blunt blows due to their anatomic relative fixation within the retroperitoneal space and by the ligament of Treitz allowing for compression against the vertebral column. , , ,
The proposed mechanism for uncommonly seen abusive adrenal gland injuries includes direct force, an acute rise in venous pressures, and vascular shearing due to deceleration.
Mechanisms of injury reported causing abusive pharyngeal and esophageal injuries include foreign body ingestion, forceful insertion of blunt objects or fingers, penetrating external trauma, or strangulation. , , ,
Abusive intrathoracic injuries have been reported to also occur from blunt impacts, with one study concluding that abusive intrathoracic injuries were typically caused by lower velocity compressive or crushing mechanisms versus high-velocity blunt impacts in accidental intrathoracic injuries.
Maguire’s systematic review of visceral trauma cites several case reports highlighting penetrating trauma from the insertion of needles into the chest, abdomen, neck, and arm as a less common mechanism of injury in abusive visceral trauma. , ,
Nature of pediatric abusive visceral injuries
The nature of visceral injuries occurring as a result of physical abuse is well documented in literature. What follows is a brief description of the types of pediatric abusive visceral injuries reported in literature along with some important features the pediatric clinician should be familiar with when assessing children where physical abuse is a consideration.
Pediatric Intra-abdominal Visceral Organs
Hollow organs
The most frequently injured hollow organ in child physical abuse is the small bowel, specifically the duodenum and the proximal jejunum with one series reporting bowel injury in 50% of abdominal abusive injuries. Injuries to the stomach and large intestine have also been reported. , , , ,
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Small bowel injuries include localized hematomas, complete transections, perforations, and inflammation. , , These injuries may have co-occurring mesenteric tears or contusions. Intramural hematomas are often located in the second and the third portions of the duodenum resulting from a partial thickness tear with resultant subserosal bleeding , and can cause varying degrees of obstruction leading to delayed diagnosis. , Perforations most commonly occur in the jejunum up to 60% and are the result of a full-thickness injury to the intestinal wall. Complications associated with mesenteric lesions include bowel ischemia and subsequent development of bowel strictures. Peritonitis is an associated complication of bowel perforation requiring surgical intervention.
Duodenal injuries , in particular, are highly associated with physical abuse in children aged less than 3 years. , Duodenal perforations and transections typically occur between the third and fourth part of the duodenum, which is the fixed portion of the organ owing to location within the retroperitoneal space and is noted as the most common abusive hollow organ injury in several studies. , Duodenal injuries were also often associated with numerous other traumatic abusive injuries. ,
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Gastric ruptures have infrequently been reported. It is important to recognize this rare presentation of abusive visceral trauma, as unrecognized gastric ruptures have been reported to lead to sepsis, shock, and death. Other rarely reported gastric injuries include intramural hematoma and distention secondary to duodenal obstruction.
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Large bowel injuries resulting from child abuse are rare but have been reported as intramural hematomas, colonic contusions, colonic serosal tears, meso-colonic tears, rectal perforation, and pneumatosis intestinalis. , , , , ,
Solid organs
Intra-abdominal solid organs are the most frequently injured in trauma, especially the liver and pancreas, though injuries to the bowel are disproportionately increased in young, abused children. , Forceful compression of solid organs against the spinal column can cause solid organ fractures and hematomas.
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The liver has been noted to be injured in both accidental and abusive scenarios with similar regularity. , , This visceral organ is injured in physically abused children with the preponderance of injuries occurring to the left lobe of the liver, likely owing to its location and vulnerability to compression abutted to the spinal column. , Liver injuries are graded according to the American Association for the Surgery of Trauma (AAST) liver injury scale. Those that have been described in physical abuse include complete transections, lacerations, contusions, and subcapsular hematomas. , , Bile duct injuries and gas in the portal vein have also been reported.
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The spleen has also been noted to be injured in accidental and abusive scenarios with similar regularity, , but is overall infrequently reported , in abusive injuries possibly because of the relative protection of the spleen by the thoracic cage. , , It is the second most commonly injured solid organ after the liver , and was reported in 7% in one series of 84 abused children and 21% in another series of 24 abused children with intra-abdominal trauma. Like the liver, splenic injuries are graded according to the AAST spleen injury scale. Abusive splenic injuries that have been described include lacerations, fractures, hematomas, and ruptures with rare complications that can include pseudoaneurysms and delayed growing cysts.
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Trauma is the leading cause of pancreatitis in children with estimates of up to one-third caused by physical abuse. Physical abuse accounted for 8.6% of non–motor vehicle-associated intra-abdominal injuries in one series of 664 children with a mean age of 2.6 years. The pediatric clinician should thus evaluate any young child presenting with traumatic pancreatic injury for abuse without a clear history of MVC or bicycle handlebar injury. The types of abusive pancreatic injuries reported include lacerations and transections, which can both result in the extracomplication of pseudocyst formation, acute necrotizing pancreatitis, and chronic pancreatitis. As another retroperitoneal organ juxtaposed with the spinal column and vulnerable to compression with blunt force trauma, lacerations most commonly occur at the junction of the pancreatic body and tail. Abusive pancreatic injuries are associated with significant morbidity and mortality and were noted to be the second most common cause of fatality in children who died from abusive injuries. , , , , , The pediatric clinician should also be aware of a late complication occurring from 2 to 10 weeks after blunt pancreatic injury whereby the systemic release of pancreatic enzymes can cause fat necrosis and result in osteolytic lesions, which has been reported in children with abusive pancreatitis. , Lesions are typically located on the lower extremities and the small bones of the feet, and can be associated with fever, and painful swelling over the top surface of the feet.
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Adrenal gland injuries have been reported in children who are physically abused, , noted to be unilateral and right sided in a series of 5 cases of adrenal hemorrhage, and associated with another solid organ injury or rib fractures on the same side. The types of injuries reported include hematoma, laceration, and complete transection, which were all associated with bruising to the abdomen/trunk and the presence of additional traumatic injuries. , ,
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Damage to lymphatic structures in the bowel, mesentery, or retroperitoneum can result in chylous ascites, the accumulation of chylous fluid within the abdominal cavity. One series found that up to 10% of chylous ascites cases in children were due to physical abuse. Similarly, disruption to the thoracic duct can result in chylothorax and has also been reported in child physical abuse. , The reported cases have been associated with rib fractures as well as other types of fractures, which aided in the clarification of diagnosis of child maltreatment. The pediatric clinician should approach an isolated finding of chylothorax with a thorough history, examination, and appropriate testing for other occult injuries as indicated as there are numerous medical etiologies for chylothorax.
Urogenital tract
Injuries to the organs making up the urogenital system including the kidneys, bladder, and scrotum are relatively rare in abused children but have been reported. , , , , Acute renal failure has rarely been reported after severe rhabdomyolysis followed by myoglobinuria in cases of substantial abusive soft tissue muscle injuries.
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Kidney injuries are uncommon with abuse and are usually discovered in association with other injuries , , , , and can be seen as either overt injury or isolated hematuria in near 25% of abusive intra-abdominal injuries and in up to 19% of hospitalized children with abusive intra-abdominal trauma. Kidney injuries are graded according to the AAST kidney injury scale. The types of abusive renal injuries reported include hematomas to and around the organ, lacerations, and contusions typically from blunt impact. Renal vascular and collecting duct abusive injuries have been reported and are typically the result of deceleration. ,
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Abusive bladder injuries have also rarely been reported following a direct blow to a full bladder with tears to the dome, the weakest area of the bladder, in children ranging in age from 10 months to 6 years. , , Many of these children had delayed presentations and had overt clinical symptoms including varied stages of renal failure and acute abdomen. Also described are rare mechanisms like needle insertions and a tourniquet injury, which caused bilateral hydronephrosis and hydroureter in a 2 year old boy who died from his injuries.
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Abusive injuries to the scrotum are well known to occur in both sexual and physical abuse. Hematomas in this location may be the first sign of intraperitoneal hemorrhage and significant intra-abdominal injury in an abused child.
Pediatric neck/thorax organs
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Abusive injuries to the organs within the neck that are in continuum with the organs of the thorax have been reported to include life-threatening perforations of the pharynx, including the lower portion of the pharynx or hypopharynx, and the esophagus. Young children presenting with abusive injuries in these locations have been reported to present with subcutaneous and interstitial emphysema, pneumomediastinum, retropharyngeal abscess, and associated additional inflicted traumatic injuries. , Among many of the cases reports, children presented with respiratory distress, oral bleeding, or upper airway obstruction.
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Abusive injuries to the heart and aorta have rarely been reported as a result of direct trauma and include ventriculoseptal defects, right atrial lacerations and intimal tears, a laceration of the apical left ventricle, a traumatic right atrial aneurysm, aortic pseudoaneurysm, and an abdominal aortic transection in children aged from 9 weeks to 5 years. , , , There was a high mortality rate in the children presenting with these injuries (∼50%), and many presented with additional traumatic injuries including liver injuries, rib fractures, and one child with a hyperextension lumbar vertebral dislocation fracture. , , Needle insertion has also been a reported abusive cardiac injury. Commotio cordis, known to occur from specific timing of an impact to the chest directly over the heart resulting in cardiac arrhythmia and sudden cardiac arrest, has also been reported in both accidental and abusive scenarios. , ,
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Injuries to and around the lungs have also been described in physically abused children and include pulmonary contusion, perforation/laceration, pneumothorax, hemothorax, and pleural effusions. , , Children presented with respiratory distress or failure, flail chest, some of whom also had additional traumatic injuries including rib fractures, chylothorax, other fractures, liver and other intra-abdominal organ injury, and head injury. , ,
Evaluation
Pediatric clinicians should approach the medical evaluation of infants and children where physical abuse is a concern in consideration of intra-abdominal injury with objectivity and an appropriate healthy index of suspicion while utilizing the most current and best evidence-based guidelines. The pediatric clinician who is familiar with the American Academy of Pediatrics (AAP) Clinical Report on The Evaluation of Suspected Child Physical Abuse in AAP’s Pediatrics journal will have a strong foundation of knowledge that can be added upon in consideration of additional and directed evaluation of intra-abdominal injury. Consultation with a child abuse pediatrician is also an invaluable resource for the pediatric clinician encountering a young child where child abuse is a concern.
Laboratory Testing
Understanding the limitations of history, physical examination findings, and clinical signs and symptoms in the identification of pediatric intra-abdominal abusive injuries, several studies have attempted to identify which screening laboratory tests are best able to predict the presence of often clinically occult intra-abdominal injury and best inform the need for further diagnostic testing.
Transaminases
Alanine transaminase, an enzyme found in the liver, and aspartate transaminase, found in the liver, skeletal muscle, and pancreas, are recognized as markers that can help in the identification of abdominal injury, specifically liver injury. Several studies from 1984 to 2013 have investigated transaminases as a marker for liver injury, , , with most recent studies suggesting using a cutoff of 80 IU/L. , , Coant and colleagues found an association with elevated transaminases and lactate dehydrogenase in three-fourths children found to have liver laceration on definitive testing with an abdominal CT. Lindberg and colleagues’ 2009 prospective multicenter observational Utilizing Liver Transaminases to Recognize Abuse (ULTRA) study examined the use of clinical signs and laboratory testing in the diagnosis of intra-abdominal injury. Though this was limited in that there was a lack of uniform use of a definitive diagnostic test (eg, CT, MRI, surgery, and autopsy) which occurred in 255 of 1676 children, it provided invaluable information in relation to the establishment of a cutoff value of 80 IU/L with a sensitivity of 77%, a specificity of 82%, and positive predictive value of 16%. In follow-up, Lindberg and colleagues’ 2013 retrospective secondary analysis of the examining siblings to recognize abuse (ExSTRA) dataset similarly showed a sensitivity of 84% and specificity of 82% for abdominal injuries using this same cutoff value. Overall, these studies indicate that elevated values warrant strong consideration for definitive testing with an intravenous contrasted abdominal CT in this high-risk population.
Pancreatic enzymes
Amylase and lipase are enzymes produced by the pancreas and can be a marker of injury when elevated. Studies evaluating their utility with actionable cutoff values in determining pancreatic injury are not as strong as transaminase studies and association with liver injury; however, research from the ULTRA study suggests a cutoff amylase value of 50 U/L with a sensitivity of 63% and specificity of 78% and a cutoff lipase value of 100 U/L with a sensitivity of 62% and specificity of 79%. Interpretation of these values is complicated by the fact that they are within normal reported ranges. Hilmes and colleagues noted an elevation in amylase or lipase in 50% of the children in their study who were found to have intra-abdominal injury and in another 14% who had a normal CT. Again, elevated values warrant strong consideration for definitive testing with an intravenous contrasted abdominal CT in this high-risk population.
Urinalysis
Identification of occult injury to viscera of the urogenital tract has been studied recently to examine the utility of a screening urinalysis when child abuse is suspected in a case series of 237 children aged less than 7 years with suspicion of child abuse who all had a urine dipstick performed, 52 (22%) of whom had clinical signs and symptoms of intra-abdominal trauma. This series found hematuria in 24 (10%) children, 19 (79%) of whom had abdominal imaging, in which there were 8 (42%) intra-abdominal injuries (liver, spleen, adrenal gland, and pancreas). Three children had 3 kidney injuries. Prior to this study, hematuria had only been found in 1 child out of 26 who had a urinalysis completed in their series of 49 clinically asymptomatic children. Urinalysis showing hematuria alone did not detect kidney injury in this recent study and all of the children with intra-abdominal injury had other positive laboratory and clinical indicators of intra-abdominal injury. Thus, utilization of urinalysis as a routine screening test for occult urogenital tract injury is not strongly recommended.
The pediatric clinician should remember that laboratory screening tests that are available and have been studied for the detection of occult abusive intra-abdominal injury are not inclusive of all intra-abdominal viscera, like the spleen, adrenal glands, and hollow organ; therefore, approaching children with potential abusive internal injury requires clinical vigilance.
Imaging
When abusive abdominal injury is suspected in any child, the radiological assessment is the same as for a child with accidental abdominal injuries, though indications should include forensic as well as clinical implications. Radiological modalities provide invaluable and often diagnostic and forensic information about the varied visceral injuries in physically abused children. Radiological imaging can also help guide management and help in the clinical assessment of critically ill children who present with a decreased level of consciousness.
Computed tomography
Abdomen and pelvis CT with intravenous (IV) contrast is the recommended imaging study of choice in the evaluation of children when there is concern for abusive intra-abdominal injury. , Contrast aids in the delineation of parenchymal and vascular injury. In consideration of the risk associated with radiation exposure, the concept of “as low a dose as is reasonably achievable” principles should be followed, , while also considering the additional risk of missing an occult injury that places a child at the risk of recurrent and escalating injury without appropriate intervention. The CT is additionally useful in the assessment of potential bone injuries/fractures, can be especially helpful with questionable findings on the skeletal survey, and with 3D reconstruction protocols, aid in better visualization. The use of newer generation helical scanners has improved the identification of pancreatic and hollow organ injuries even further.
Ultrasound
In Focused Assessment with Sonography for Trauma (FAST), ultrasound is often used in the assessment of adults presenting with trauma to look for hemoperitoneum. This modality is not recommended for use in children in the assessment of abusive intra-abdominal injuries because hemoperitoneum may be absent in children with abusive intra-abdominal injury and because the overall detection rate is poor in this population. One meta-analysis found a sensitivity rate as low as 66% in the detection of hemoperitoneum in children. While the conventional ultrasound is also not a recommended study modality to detect intra-abdominal solid organ injuries in this population, , the contrast-enhanced ultrasound (CEUS) is an appealing and promising potential modality. CEUS uses a nonnephrotoxic, nonradiating contrast agent made up of gas microbubbles inside a phospholipid or albumin shell that is expelled upon exhalation through the lungs. , This study has fairly high sensitivity rates in detecting solid organ injuries in comparison to CT ranging from 86% to 100%. , Current recommendations include the use of CEUS to address CT findings of unclear significance.
Several imaging modalities can help evaluate potential visceral injuries in children and are summarized in Table 2 . , ,
| Injured Viscera | Best Study | Findings |
|---|---|---|
| Hollow organs ∗ Esophagus, stomach, and small bowel | IV-contrasted abdomen and pelvis CT ∗ Consider upper gastrointestinal study with water-soluble contrast in stable child | |
| Adrenal glands | IV-contrasted abdomen and pelvis CT |
|
| Kidneys | IV-contrasted abdomen and pelvis CT (with normal renal function) Immediate and delayed phases on CT is helpful to assess the renal parenchyma and the collecting system |
|
| Pancreas ∗ Ductal injuries ∗∗ Pseudocysts | IV-contrasted abdomen and pelvis CT ∗ MRI can be helpful adjunct ∗∗ Visible in traditional ultrasound |
|
| Liver | IV-contrasted abdomen and pelvis CT |
|
| Spleen | IV-contrasted abdomen and pelvis CT |
|
| Pharynx/hypopharynx | Cervical plain films AP/Lat CXR Cervical and/or Chest CT Barium Swallow Study |
|
| Lung | AP/Lat CXR Chest CT ∗ May see injuries on IV-contrasted abdominal pelvis CT |
|
| Heart/cardiovascular structures | Chest CT Angiogram |
|
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