*4.1.1 General consideration*

Both of the useful and dangerous microorganisms have been with human beings for many years. Human body is ever colonized by useful microorganisms so called normal flora. Evidences have shown that these organisms play substantial role in defense mechanism for normal human being. However, due to certain circumstances such as injuries, and compromised immunity these microorganisms escape their usual habitants and reach sterile site of the body which eventually results into infections. Typically infections can be defined as an invasion and destruction of tissues by microorganisms. Various factors influence the occurrence of infections to humans. For hospitalized non-operated traumatic abdominal patients, among the factors which influence infectious complications include: (1) presence of superficial lacerations, (2) missed and unrepaired hollow viscus injuries, (3) Overcrowded wards of which abdominal trauma patients are mixed with other patients who have other surgical


#### **Table 9.**

*Possible complications to associate with non-operative management of abdominal trauma.*

conditions, (4) non-adherence to infections control measures, (5) Compromised immune status of the patient, (6) Starvation, (7) shock, and (8) prolonged hospital stay etc. These factors can influence the occurrence of principal infectious complications such as sepsis and septic shock, peritonitis and nosocomial infections for nonoperated hospitalized traumatic abdominal patient.

#### *4.1.2 Sepsis and septic shock for non-operated hospitalized traumatic abdominal patient*

The initiation and progression of infection process for non-operated abdominal trauma patient occur via several routes. For instance traumatic abdominal patient with superficial wounds are at risk of developing infections due to immediate colonization of their wounds by normal flora. Usually humans mount both local and systemic responses to microorganisms that have escaped their usual habitants. Infections provoke the process of inflammation. Classic features (pain, warmth, redness, swelling and loss of functions) of inflammation may appear as signs for either local or systemic response to infections. Local metabolic effects of infections are due to tissues damage with cells deaths and buildup of proteins rich exudate of leukocyte, immuglobulins, and plasma; these are visible externally as pus.

Untreated or poorly treated local infections may result into catastrophic results that initiate systemic responses. Systemic inflammatory response syndrome (SIRS) is evident clinical when there are two or more of the following findings: (1) fever (oral temperature (>38°C), or hypothermia (< 36°C), (2) tachypnea (> 24 breaths/ minutes); (3) tachycardia (heart rate > 100 beats/minute, and (4) leukocytosis (>12,000/μL) and leukopenia (400 < μL). Sepsis should be diagnosed when evidence (results of culture) shows that infections are the responsible cause of SIRS. Sepsis marks the inability of cell to use nutrients.

Untreated or poorly treated sepsis progress to septic shock. Septic shock can be in two forms namely: warm phase, and cold phase. In warm phase, there is increased peripheral circulation in attempt to deliver enough blood to the cells. High temperature marks this phase. This phase is transient and failure to treat the patient with an appropriate therapy leads to un-compensatory shock (cold phase). The dangerous outcome of septic shock include: low flow state (volume reduction), tissue injury, pump failure (heart) and more infections. The diagnosis of septic shock is made if there is sepsis and hypotension (arterial blood pressure < 90 mmHg systolic or 40 mmHg less than patient's normal blood pressure) for at least 1 hour regardless of satisfactory fluid resuscitation. Early recognition of septic shock and institution of appropriate therapies can be useful in terms of saving the life of the patient.

#### *4.1.3 Peritonitis*

#### *4.1.3.1 Description*

Peritonitis is life threatening condition which is associated with abdominal trauma. The association between NOM and peritonitis depends on the fact of missing perforation of hollow viscous organ. "Injuries to the stomach, duodenum, small intestine, and colon are common in penetrating trauma and relatively rare in blunt trauma. Violation of the peritoneum occurs in between 20 and 80% of patients with penetrating trauma, depending on the type of weapon used" [11]. Both of the pillage of abdominal contents and blood into the peritoneal cavity irritates peritoneal membrane. Persistent non-repaired perforation of hollow viscus abdominal organ

exacerbates the process of inflammation due to continuous spillage of GIT contents into the peritoneal cavity. Moreover, severity of peritonitis can depend on perforated hollow organ. For instance, when stomach or duodenum has been perforated, the severity is high because of the spillage of contents of low PH and some microorganisms.

#### *4.1.3.2 Clinical manifestation and treatment*

The clinical manifestations of peritonitis may include, fever, rigidity, guarding, signs of toxemia and shock etc. Early recognition and institution of treatment approach is lifesaving. Firstly, stabilize the patient; ensure adequate ventilation, breathing and circulation. Administer fluids and antibiotics. Secondary proceed to the repair of perforated viscus organ. And finally provide postoperative and long term care in order to detect and treat any complications which can occur after an operation.

#### **4.2 Hematoma formation**

#### *4.2.1 Description*

Hematoma formation is a common outcome to occur following abdominal trauma. Hematoma can form within the tissue or outside the tissue due to damage of blood vessels. Blood that has accumulated coagulate and results into hematoma. The association between NOM of abdominal trauma and hematoma formation as a complication lies on the fact of making a wrong decision. Certain imaging modalities can assist to stage hematoma and support to make best choice regarding management approach. Evidence has shown that stage 1 and 2 of hematoma resolve spontaneously in contrast to stage three and above which should be managed via operative approach. Lack of imaging modalities to decide which stage of hematoma the patient has developed is a common factor leading to the use of wrong management approach. When a certain unrepaired blood vessel continues to bleed more blood accumulate and hematoma continue to form. Untreated hematoma may serve as culture medium for microorganisms because accumulated blood lyses and release cellular contents such as iron which is good nutrients of microbes. As such hematoma can be a focus of infections which may turn into sepsis. The use of antibiotic as prophylaxis for infections associated with hematoma seems not to be effective because hematoma does not allow the entrance of antibiotics.

#### *4.2.2 Clinical features*

Manifestations of hematoma depend on its location, size and whether it has ruptured or infected by microbes. History of abdominal trauma and left upper quadrant pain and positive balance sign (immovable mass or immovable area of dullness in the left upper quadrant) point to splenic sub-capsular or extra-capsular hematoma. The pain may occur due to big size of hematoma which compresses nerves, capsule and other tissues to result into ischemia. Signs of hemodynamic instability may be present if hematoma has undergone rupture. Moreover, if hematoma has been infected by microorganisms, signs of infections may be apparent; evidence of infections should infer quick interventions because untreated infections may turn into sepsis, septic shock; perhaps death.

#### *4.2.3 Treatment approach*

Evacuation is treatment of choice for hematoma. Evacuation of hematoma diminishes successive inflammatory reactions to the initial insult. But also, diminish damage associated molecular patterns (DAMPs) and successive diffuse organ injury. Operating on hematoma is challenging due to risk of bleeding. While managing patient with abdominal hematoma, physician should remember to treat other complications which would have occurred or as they occur. Treatment or prevention of hypovolemic shock and infections is highly needed.
