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What are the features of abusive abdominal injury? a systematic review
  1. M Haroon1,
  2. M Mann2,
  3. V Tempest3,
  4. R Lumb3,
  5. A Kemp3,
  6. S Maguire3
  1. 1Community Paediatrics, Leicestercity PCT, Leicester, UK
  2. 2Information Services, Cardiff University, Cardiff, UK
  3. 3Child Health, Cardiff University, Cardiff, UK

Abstract

Aims Abusive abdominal injuries carry significant morbidity and mortality, yet are rarely recognised. The authors aim to determine the prevalence and characteristics both clinically and biochemically.

Methods The authors performed a literature search of databases, websites and references from 1950 to 2009. Of 2352 abstracts, 180 studies underwent two independent reviews using standardised criteria, with a third review if there was disagreement. Inclusion criteria: primary studies of children <18 years with confirmed abuse (abuse rank 1–3), injury confirmed by CT/contrast studies/laparotomy/postmortem. Exclusion criteria: anogenital injuries, solely management/outcome studies, accidental injuries alone. Where appropriate, a random effects proportion meta-analysis was performed.

Results Overall, 58 studies (854 children; 103 with abusive abdominal injuries) were included. Of these, <10% (range 0.5–0%) of abused children sustained abdominal injuries, with a mortality of 30–47%. The commonest injuries were to the bowel (pooled proportion=0.45) and liver (0.48), predominantly affecting small bowel. Accidental bowel injuries (from falls) did not occur in children <5 years (mean age of children admitted with visceral injuries due to falls=10.39 years, mean age of visceral injury due to abuse=3.73 years). Common symptoms included vomiting (bilious and non-bilious), abdominal distension and tenderness; while bruising elsewhere on the body was frequently present, abdominal bruising was often absent (40–90% of cases). Coexistent fractures were recorded in 27–35% of cases. Three studies evaluated the diagnostic utility of alanine transaminase (ALT)/aspartate transaminase (AST) for liver trauma associated with abuse. Varying cutoffs were suggested as indicating liver trauma including AST:ALT>1.

Conclusion Abdominal injury should be considered in any physically abused child, as symptoms may be non-specific. The absence of local bruising does not preclude significant injury. Small bowel injuries in young children have a strong association with abuse, but liver injury is also common. Measurement of AST and ALT may assist in assessing for occult abdominal injury and may be useful prognostically.

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