1. Koksal, Aydn Seref MD
  2. Suna, Nuretdin MD
  3. Bilge, Zulfukar MD
  4. Yldz, Hakan MD
  5. Eminler, Ahmet Tark MD
  6. Oztas, Erkin MD
  7. Parlak, Erkan MD

Article Content

Blunt abdominal trauma is one of most common causes of admission to trauma centers. Hollow organ injuries due to blunt abdominal trauma, however, are unusual and generally occur in the small bowel (Tejerina Alvarez et al., 2004; Watts & Fakhry, 2003). Blunt traumatic injury of the stomach is very rare and has been reported in a few case reports (Bruscagin et al., 2001; Burke & Harley, 1983). The stomach is a highly mobile organ with thick muscular walls and has a relatively protected location; therefore, a strong impact is required for its injury. Injury of the stomach has the highest mortality among all hollow organ injuries (Watts & Fakhry, 2003).


Gastric injury is classified into four grades, based on the gastric organ injury scale (Table 1) (Moore et al., 1995). Grade I level of injury constitutes 60% of all cases. Full-thickness tear or rupture constitutes nearly 40% of all cases (Bruscagin et al., 2001; Shinkawa et al., 2004). Herein we present a case that developed kissing gastric ulcers and melena after a blunt abdominal trauma.

Table 1 - Click to enlarge in new windowTABLE 1. Stomach Injury Scale

Case Report

A 20-year-old male patient was admitted to the emergency department of our hospital with a new onset of black, tarry stool. He was a nonsmoker and denied using any over-the-counter agents including nonsteroidal anti-inflammatory drugs (NSAIDs). His medical history revealed that 3 months ago, he underwent an upper gastrointestinal endoscopy because of halitosis, which showed pangastritis, and received 1 month of proton pump inhibitor (PPI) treatment for that. He had no gastrointestinal symptoms since then. Twelve hours before admission, he got in a fight and was kicked in his abdomen and chest. Physical examination was normal other than tenderness during palpation in his abdomen and chest. Laboratory analysis revealed a slight anemia (hemoglobin = 12 g/dl) with normal biochemical tests and prothrombin time internationalized ratio. Endoscopy showed two deep circular kissing gastric ulcers located in the anterior and posterior walls of the distal corpus and nodular gastritis in the antrum. The ulcers were approximately 11-13 mm in size, had clean bases covered with whitish exudate, and regular contours surrounded by hemorrhagic mucosa (Figure 1). Biopsy samples obtained from the margin and base of the ulcers revealed Helicobacter pylori (Hp). Abdominal ultrasonography and tomography were normal. The patient was diagnosed as having gastric ulcers due to blunt trauma to the stomach and was put on an Hp eradication procedure, followed by PPI treatment.

Figure 1 - Click to enlarge in new windowFIGURE 1. Deep kissing gastric ulcers located in the anterior and posterior walls of the distal corpus.


Most traumatic gastric injuries are accompanied by injuries of other organs such as liver, spleen or pancreas, thorax, or extremities (Shinkawa et al., 2004; Tejerina Alvarez et al., 2004). Isolated gastric injury due to blunt abdominal trauma is rare. There are certain modes of traumatic gastric injury. Blunt trauma may increase the stomach pressure and the risk of perforation in a distended stomach. Other modes of stomach injury are deceleration and crush (Benatta, 2012; Burke & Harley, 1983). In crush injuries, the impact force compresses the stomach against the spine. This mode of injury can explain the mechanism of mucosal damage in our patient.


The stomach injury after blunt trauma can be potentially mortal; therefore a high index of suspicion is needed. Endoscopic examination should be performed in patients who developed melena due to blunt abdominal trauma after exclusion of perforation. Gastric mucosal damage can be treated conservatively and recovery is confirmed with a radiological or endoscopic evaluation.


Hp-associated gastritis and ingestion of NSAIDs are the two most common causes of gastric ulcer. Gastric ulcer resulting from direct blunt trauma to the stomach is very rare (Burke & Harley, 1983; Saeb-Parsy, Omer, & Hall, 2006).


Kissing gastric ulcers due to blunt trauma has been reported in a single case report (Saeb-Parsy et al., 2006). A 15-year-old boy sustained a bicycle handle bar injury to the abdomen and presented to the emergency department 4 days later with melena. Upper gastrointestinal endoscopy revealed two kissing areas of mucosal ulceration on the anterior and posterior walls of the gastric antrum, which were completely healed by PPI treatment.


Kissing ulcers are defined as a pair of ulcers on the opposite sites of the duodenum or stomach. They constitute 1.5% of all duodenal ulcers (Galban, Arus, & Periles, 2012). There are only two case reports of kissing gastric ulcers in the literature (Mensier, Bounoua, Beretvas, Mosoi, & Dardenne, 2013; Saeb-Parsy et al., 2006). One of them was due to use of NSAIDs and the other one was traumatic. In our patient, the presence of gastritis on endoscopy that was performed 3 months before the trauma, asymptomatic nature of the patient since then, and an onset of melena 12 hours after trauma to the stomach suggested a causal relationship between the trauma and gastric ulcers. Furthermore, the location of gastric ulcers suggested a traumatic etiology because of the possible contact of the contralateral sides of the corpus due to blunt trauma.




Benatta M. A. (2012). Blunt gastric traumatic injuries: A case revealed at endoscopy. Annals of Gastroenterology, 25, 352. [Context Link]


Bruscagin V., Coimbra R., Rasslan S., Abrantes W. L., Souza H. P., Neto G., Ribas J. R. (2001). Blunt gastric injury. A multicentre experience. Injury, 32, 761-764. [Context Link]


Burke A. M., Harley H. A. J. (1983). Traumatic gastric ulceration. Australian and New Zealand Journal of Surgery, 53, 379-380. [Context Link]


Galban E., Arus E., Periles U. (2012). Endoscopic findings and associated risk factors in primary health care settings in Havana, Cuba. MEDICC Review, 14, 30-37. [Context Link]


Mensier A., Bounoua F., Beretvas G., Mosoi A., Dardenne S. (2013). Kissing gastric ulcers causing acute pancreatitis and portal biliopathy: What's the link? JOP, 14, 646-648. [Context Link]


Moore E. E., Jurkovich G. J., Knudson M. M., Cogbill T. H, Malangoni M. A., Champion H. R., Shackford S. R. (1995). Organ injury scaling. VI: Extrahepatic biliary, esophagus, stomach, vulva, vagina, uterus (nonpregnant), uterus (pregnant), fallopian tube, and ovary. Journal of Trauma, 39, 1069-1070. [Context Link]


Saeb-Parsy K., Omer A., Hall N. R. (2006). Melaena as the presenting symptom of gastric mucosal injury due to blunt abdominal trauma. Emergency Medicine Journal, 23, e34. [Context Link]


Shinkawa H., Yasuhara H., Naka S., Morikane K., Furuya Y., Niwa H., Kikuchi T. (2004). Characteristic features of abdominal organ injuries associated with gastric rupture in blunt abdominal trauma. American Journal of Surgery, 187, 394-397. [Context Link]


Tejerina Alvarez E. E., Holanda M. S., Lopez-Espadas F., Dominguez M. J., Ots E., Diaz-Reganon J. (2004). Gastric rupture from blunt abdominal trauma. Injury, 35(3), 228-231. [Context Link]


Watts D. D., Fakhry S. M. (2003). Incidence of hollow viscus injury in blunt trauma: An analysis of 275,557 trauma admission from the East multi-institutional trial. Journal of Trauma, 54, 289-294. [Context Link]