Assessment of Pattern of Abdominal Injury over a Two-Year Period at St Paul's Hospital Millenium Medical College and AaBET Hospital, Addis Ababa, Ethiopia: A Retrospective Study

Background Globally, injury continues to be an important cause of morbidity and mortality both in developed and developing countries. Abdominal injuries are among the major causes of trauma admissions. This study aimed to assess patterns of abdominal injury at AaBET and St. Paul's Hospital Millennium Medical College. Methods A cross-sectional study was done on all adult patients who sustained abdominal injuries presented to the emergency department and managed at AaBET and St. Paul's Hospital Millennium Medical College over a two-year period from January 2018 to December 2019. Results A total of 165 abdominal injured patients presented during the study period. Among those patients, 140 (84.8%) were male, with a male-to-female ratio of 5.61. The mean age of patients was 29.3 years. 85 (51.5%) of the patients sustained penetrating injuries. 53 (32.1%) patients sustained road traffic accidents, 47 (32.1%) had stab injuries, and 34 (20.6%) had gunshots. Thirty-four (20.6%) of the patients were managed conservatively and 79.4% (n = 131) were managed surgically. The commonest complications found were shock (n = 20 (12.1%)), peritonitis (n = 18(10.9%)), HAP (n = 9 (5.5%)), and surgical site infection (n = 4 (2.4%)).The mortality rate was 3.6% (n = 6), of which 4 (67%) had the penetrating mechanism of injury. Conclusion Abdominal trauma predominantly affects the male and economically productive age. The three main causes of abdominal injuries in this study were road traffic accidents, stab injuries, and gunshots, which require increased public awareness of the need to prevent road traffic accidents and to handle weapons and sharp items properly.


Background
According to the World Health Organization's (WHO) global burden of injury estimate ranks injury is one of the top ten leading causes of death, with an estimated 5 million deaths annually, among which men in Africa have the highest injury-related mortality rates in the world [1]. Trauma is the second largest cause of illness, accounting for 16% of the global disease burden, and it is the highest between the ages of 15 and 45 years. According to WHO, lowand middle-income countries account for more than 90% of all injuries. Africa, mainly the Sub-Saharan region, contributes 21% of these [2]. e abdomen is vulnerable to injury since there is minimal bony protection for underlying organs [3]. e etiological spectrum and mechanism of injury of abdominal trauma, which have been reported in the literature, vary from one part of the world to another, partly because of variations in infrastructure, civil violence, wars, and crime [4]. Abdominal trauma poses a diagnostic challenge to general surgeons and professionals practicing in resourcelimited countries [5]. e management of patients with abdominal trauma has several important elements: adequate prehospital care; rapid transport to a specialized Centre; complex in-hospital care; and rehabilitation. In recent years, many abdominal injuries, especially those involving solid organs are managed nonoperatively. is has been made possible by the invention of imaging techniques like ultrasonography, computerized tomography (CT) scanning, and magnetic resonance imaging (MRI), which show the site and extent of the injury [6][7][8].
is study aimed to assess the pattern of abdominal injuries at St Paul's Hospital Millennium Medical College (SPHMMC) and Addis Ababa Burn, Emergency and Trauma (AaBET) hospital, Addis Ababa, Ethiopia.

Methodology
is hospital-based cross-sectional study was done at SPHMMC and AaBET hospitals from January 2018 to December 2019. SPHMMC is one of the tertiary referral hospitals in Addis Ababa, Ethiopia, established in 1968. e hospital serves around 15,000 emergency visits a year and has around 700 inpatient beds. AaBET Hospital is an affiliate of SPHMMC in Addis Ababa, Ethiopia, established in 2015 for quality improvement to improve emergency, burn, and trauma care. e hospital provides emergency, critical care, general surgery, neurosurgery, and orthopedic service.
In this study, we included all patients clinically diagnosed to have an abdominal injury who presented to SPHHMC/AaBET Hospital from January 2018 to December 2019. Patients who died before diagnosis and patients treated at other hospitals and referred for other reasons were excluded.

Operational
Definition. Blunt abdominal injury: is defined as damage to the abdomen and/or abdominal organs secondary to impact with a blunt (not penetrating) object or surface.
Penetrating abdominal injuries: are defined as injuries to the abdomen and/or abdominal organs secondary to a foreign body penetrating the abdomen and dissipating energy into the organs and the surrounding area.
Revised Trauma Score (RTS): is one of the common scores used to quantify the severity of trauma injuries based on GCS, blood pressure, and respiratory rate.
Multisystem injury: when there are injuries to more than 2 body system injury.
Combined surgery: More than two procedures done intraoperatively.

Data Collection.
Data were collected from the trauma registry and patient files using a pretested structured questionnaire filled out by two trained data collectors. e questionnaire was categorized into sociodemographics (age, sex, residency, and address), clinical profile (triage, v/s, type of injury, associated injury), management, and outcome (management, complications, disposition, and mortality). e completeness of the data were checked by the principal investigator.

Data Analysis.
e collected data was entered and analyzed using the statistical software SPSS version 25.0. Descriptive statistics were employed and summarized in the form of proportions and frequency tables for categorical variables. Continuous variables were summarized using mean and interquartile ranges (IQR).
Ethical clearance was obtained from SPHMMC IRB.

Sociodemographics.
A total of 9693 trauma patients were evaluated at AaBET and SPHMMC hospitals in the study period, of which one hundred sixty-five (1.7%) patients had abdominal trauma. One hundred forty (84.8%) were males, with a male-to-female ratio of 5 Shock (n � 20 (12.1%)) followed by peritonitis (n � 18 (10.9%)) were the most complications following surgery (Table 3).
Fifty (38.1%) of the patients had combined surgical procedure, followed by 34 (25.9%) of the patients had repair of hollow and solid organ laceration/perforation (Table 4).

Discussion
Abdominal trauma continues to be a major cause of trauma admission all over the world and contributes significantly to high morbidity and mortality [3]. e majority of the patients in this study are in their 2 nd to 4 th decade of life, which represents the economically productive age group in Ethiopia, and this finding conforms to observations made by a study from Tanzania [9]. Even though we did not assess use of alcohol and drugs, other studies suggest high use in this age group [10].
In this study, more males (75.3%) were affected than females, with a male-to-female ratio of 5.6 : 1, and this is also comparable with other studies done in our setting [11]. is might be due to male's engagement in high-risk activities; and male are bread earners of most households and are 2 Emergency Medicine International probably more involved in activities that predispose them to get injured in the process of trying to earn a living and the young age group being the mobile population more involved in recreational activities like other studies [12].
In our study, penetrating trauma was the leading mechanism of abdominal injury which is in agreement with other studies [13][14][15][16][17][18]. Contrary to the above studies other researchers showed blunt injury is more common than  Emergency Medicine International penetrating [9,19].
is variation could be because of variations in the mechanism of trauma [20].
Road traffic accidents, stab injuries, and gunshots were the main causes of abdominal trauma, similar to other studies [11,13,21].
is requires national policies and implementations to decrease road traffic accidents, stab injuries, and gunshots.
Polytrauma, followed by chest and pelvic trauma, were the three main associated traumas in patients with abdominal trauma in this study. Higher associated polytrauma and a chest injury in abdominal trauma are linked with higher mortality in different studies [22]. e operative rate in the current study was 79.4%, a figure which is comparable with that Kenyatta National Hospital (70%) [18]. In operated patients, the spleen was found to be the most commonly injured intraabdominal organ in blunt abdominal injuries, whereas the colon and small bowel were injured most in penetrating abdominal injuries like in other studies [23].
If there is no apparent evidence for laparotomy, nonoperative therapy of abdominal trauma differs depending on the kind of injury (blunt or penetrating), hemodynamic condition, FAST findings, and CT scan results. Follow-up of abdominal conditions, serial hematocrit determination, ultrasound/CT if required, and admission to the observation area are all part of the nonoperative care of blunt abdominal injuries in hemodynamically stable patients without bowel injury or significant solid organ injury. Nonoperative treatment for penetrating abdominal injuries is determined by hemodynamic stability, the lack of peritonitis, and the trajectory of the stabbing or shooting damage [24][25][26][27].
e mortality rate of this study was relatively better than Kenyatta National Hospital (12.5%) [18], and operated patients' mortality in the previous same-site study (8.5%) [11].
is could be because of study inclusion criteria, injury severity differences, patient management, or clinical course.

Conclusion
Abdominal trauma predominantly affects the male and economically productive age. Road traffic accidents, stab injuries, and gunshots were the leading causes of abdominal injuries.
e research urges the development of correct

Abbreviations
AaBET: Addis Ababa Burn, Emergency and Trauma ARDS: Acute respiratory distress syndrome CT: Computerized tomography ED: Emergency department E-FAST: Extended focused assessment with sonography for trauma FB: Foreign body HAP: Hospital-acquired pneumonia ICU: Intensive care unit IRB: Institutional review board MRI: Magnetic resonance imaging RTA: Road traffic accidents SPHMMC: St. Paul's Hospital Millennium Medical College SSI: Surgical site infection UTI: Urinary tract infection.

Data Availability
e data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
e authors have all contributed equally to the conception of the work including the acquisition, analysis, or interpretation of data, drafting and revising, and final approval of the version to be published and agreed to be accountable for all aspects of the work.