Sure, it’s possible that a patient presenting with abdominal pain and tenderness following a major car crash is simply doubled over from pre-existent pelvic inflammatory disease, appendicitis, lead poisoning, or even acute intermittent porphyria.

Guess again. The traditional differential formula doesn’t adapt well to abdominal trauma. With that in mind, though, there are three considerations that warrant mention:

1. Single vs. Multi-System Trauma: Major forces inflicted by vehicles at high speeds tend to produce multi-system trauma. It is ill-considered to suppose that a patient thrown 50 feet from the train that hit him has an isolated leg fracture. Suspect the abdomen in this scenario.

2. Single- vs. Multiple-Organ Injury: There has been considerable emphasis in the past 15 years on avoiding laparotomy when there is known or strongly suspected isolated solid organ (i.e., spleen, liver) injury. This is especially true in children.¹⁰ Unfortunately, coincident hollow viscus rupture is not rare in these circumstances and can be very difficult to identify by clinical examination or certain diagnostic studies, such as CT.¹¹

3. Trauma vs. Medical: Medical problems can precipitate or coexist with trauma, especially in the elderly. Metabolic, anaphylactic, cardiac, or neurologic emergencies may cause the fall or motor vehicle crash. What appears to be closedhead injury may simply be hypoglycemia.

Patients with enlarged or abnormal intraperitoneal organs (e.g., the enlarged spleen of infectious mononucleosis) or coagulation disorders can have profound pathology subsequent to what seems to be the most trivial trauma.

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