Hollow Organ Injury: Stomach, Bowel, Peritonitis, and Delayed Presentation Practice Questions

25 multiple-choice questions on Hollow organ injury: stomach, bowel, peritonitis, and delayed presentation for paramedic and EMT students, from Chapter 37 (Abdominal and Genitourinary Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A patient with a suspected bowel injury will be flown in an unpressurized helicopter. As altitude increases, gas in the bowel will:

   1. A. Shrink and relieve the pain
   2. B. Stay the same at any height
   3. C. Dissolve into the blood
   4. D. Expand and worsen the pain
   Show answer

   Answer: D. Expand and worsen the pain

   By Boyle's law, gas expands as pressure falls, so gas in the bowel and any free air in the abdomen enlarge with altitude, which can increase distension, pain, and pressure on the diaphragm. Flying lower when possible and decompressing the stomach with a gastric tube may help. The gas does not shrink or dissolve.

2. Compared with a lower bowel injury, a perforated stomach usually causes peritoneal signs:

   1. A. Later, because acid is neutralized
   2. B. At the same time as a colon tear
   3. C. Sooner, from strong gastric acid
   4. D. After bacteria begin to multiply
   Show answer

   Answer: C. Sooner, from strong gastric acid

   Gastric acid is a potent chemical irritant, so a stomach perforation causes pain and rigidity quickly. Contents of the lower bowel are less acidic, and peritonitis there develops over hours as bacterial infection sets in.

3. Contents spilled from a perforated colon are especially dangerous because they:

   1. A. Are strongly acidic like gastric juice
   2. B. Contain enzymes that dissolve clots
   3. C. Cause immediate cardiac arrest
   4. D. Are heavily contaminated with bacteria
   Show answer

   Answer: D. Are heavily contaminated with bacteria

   Feces carry a high bacterial load, so colon perforation leads to bacterial peritonitis and sepsis over hours. Strong acid is the hallmark of stomach contents, not colon contents.

4. A 38-year-old with a seat belt sign had a normal exam on scene. Six hours later he has fever, increasing pain, and a rigid abdomen. The most likely cause is:

   1. A. A delayed splenic rupture
   2. B. A bowel injury with peritonitis
   3. C. A urinary tract infection
   4. D. A muscle strain from the lap belt
   Show answer

   Answer: B. A bowel injury with peritonitis

   Hollow organ injuries often produce few early signs, and peritonitis develops over hours as contents leak and bacteria multiply. A delayed splenic rupture would cause signs of shock, not fever with rigidity.

5. Hollow organ injuries are often missed on the initial exam because:

   1. A. Peritonitis can take hours to develop
   2. B. Bowel injuries cause early shock instead
   3. C. Rigidity appears in the first few minutes
   4. D. Bowel injuries are easily found on palpation
   Show answer

   Answer: A. Peritonitis can take hours to develop

   Bowel contents leak slowly and inflammation builds over time, so the abdomen may be soft early on. This delay is why serial exams matter and why mechanism should drive transport decisions. Isolated bowel injuries rarely cause early shock, and rigidity develops over hours rather than minutes, so a normal early exam is common and palpation alone often misses them.

6. A 30-year-old with a penetrating wound lies very still with his knees drawn up and says moving makes his abdominal pain worse. This behavior suggests:

   1. A. Renal colic from a stone
   2. B. Spinal cord injury
   3. C. Peritoneal irritation
   4. D. Simple anxiety
   Show answer

   Answer: C. Peritoneal irritation

   Patients with peritonitis lie still because any movement jars the inflamed peritoneum. Patients with renal colic, by contrast, typically writhe and cannot find a comfortable position.

7. A man shot in the abdomen has one entrance wound and no exit wound. The best conclusion is that the bullet:

   1. A. Did not enter the abdominal cavity
   2. B. Is less dangerous than a through-and-through
   3. C. Has passed out through the same hole
   4. D. Is likely still inside the body
   Show answer

   Answer: D. Is likely still inside the body

   An odd number of wounds suggests a retained bullet, whose path cannot be predicted from the skin wound and may involve the chest, pelvis, or spine. Search the whole body, including the back, buttocks, and axillae, and do not label wounds as entry or exit. A retained bullet is not less dangerous.

8. A rigid, boardlike abdomen after trauma most strongly suggests:

   1. A. Rectus muscle hematoma
   2. B. Diffuse peritonitis
   3. C. Abdominal wall contusion
   4. D. Retroperitoneal bleeding
   Show answer

   Answer: B. Diffuse peritonitis

   Generalized rigidity occurs when the abdominal wall muscles contract continuously over widely inflamed peritoneum. A rectus hematoma or wall contusion causes local tenderness or a mass rather than diffuse rigidity, and retroperitoneal bleeding often causes back or flank pain with little anterior rigidity.

9. A patient with a gunshot wound to the abdomen develops fever, tachycardia, and confusion 18 hours after a delayed presentation. You should suspect:

   1. A. Sepsis from bowel contamination
   2. B. Neurogenic shock from the bullet
   3. C. Alcohol withdrawal and delirium
   4. D. A transfusion reaction from blood
   Show answer

   Answer: A. Sepsis from bowel contamination

   Bowel contents spilled into the peritoneum cause bacterial peritonitis, which can progress to sepsis and septic shock within hours. Neurogenic shock appears immediately with spinal cord injury and causes bradycardia, not fever.

10. Bowel sounds are of little value in prehospital trauma assessment mainly because:

    1. A. They disappear after any blunt trauma
    2. B. They prove bleeding when they are present
    3. C. They are the earliest sign of shock
    4. D. They are hard to judge and change nothing
    Show answer

    Answer: D. They are hard to judge and change nothing

    Auscultating bowel sounds takes several minutes per quadrant, is unreliable in a noisy ambulance, and will not change field care. Present bowel sounds do not exclude serious injury.

11. A 21-year-old was punched hard in the upper abdomen after a large meal. Which hollow organ is most vulnerable when full?

    1. A. Stomach
    2. B. Ureter
    3. C. Appendix
    4. D. Gallbladder
    Show answer

    Answer: A. Stomach

    A distended stomach has a thin, stretched wall and can burst under a sudden pressure rise. The ureter is a narrow tube in the retroperitoneum that is rarely injured by blunt force.

12. A 12-year-old fell onto his bike handlebars and had mild epigastric pain. A day later he is vomiting green fluid. You should suspect:

    1. A. A ruptured spleen with a hemoperitoneum
    2. B. A duodenal hematoma blocking the bowel
    3. C. Gastroenteritis unrelated to the fall
    4. D. A tear of the urethra
    Show answer

    Answer: B. A duodenal hematoma blocking the bowel

    A duodenal wall hematoma can swell over hours to days and obstruct the bowel, producing bilious vomiting. Splenic rupture would show signs of shock rather than obstruction.

13. Free air under the diaphragm on an upright chest radiograph after trauma indicates:

    1. A. A ruptured splenic capsule
    2. B. An injured left kidney
    3. C. A perforated hollow organ
    4. D. A torn liver capsule
    Show answer

    Answer: C. A perforated hollow organ

    Air in the peritoneal cavity (pneumoperitoneum) must have escaped from a hollow organ such as the stomach or bowel. Solid organ injuries cause bleeding but release no air.

14. During your assessment of a trauma patient with abdominal pain, the best way to examine the abdomen in the field is to:

    1. A. Press deeply and release fast each time
    2. B. Palpate gently and avoid deep pressing
    3. C. Skip palpation if he has any pain at all
    4. D. Palpate the most painful area first, hard
    Show answer

    Answer: B. Palpate gently and avoid deep pressing

    Gentle palpation, starting away from the painful area, is enough to find tenderness, guarding, or rigidity. Deep palpation and rebound testing cause unnecessary pain and add little to field decisions, which are based on mechanism, findings, and vital signs. Palpation should not be skipped, and the painful area is examined last.

15. Why is it important to document the time of injury in a patient with a suspected bowel injury?

    1. A. Bowel injuries cannot be repaired after 6 hours
    2. B. It determines the tetanus dose needed
    3. C. Peritonitis risk rises with each hour of delay
    4. D. It is used to estimate the blood loss
    Show answer

    Answer: C. Peritonitis risk rises with each hour of delay

    Infection risk climbs as contaminated contents remain in the peritoneum, so surgeons want to know how long the leak may have been present. There is no fixed time after which bowel injury cannot be repaired, the tetanus dose depends on immunization history rather than injury time, and the time of injury does not let you estimate blood loss.

16. A 50-year-old with a stab wound to the left lower quadrant has mild pain, normal vitals, and no peritoneal signs. The most appropriate decision is to:

    1. A. Clean and dress the wound on scene
    2. B. Let him go if pain stays mild
    3. C. Probe the wound to check its depth
    4. D. Transport for surgical evaluation
    Show answer

    Answer: D. Transport for surgical evaluation

    A penetrating abdominal wound can perforate bowel even when the patient looks well, and signs of peritonitis may take hours. Probing a wound can worsen bleeding and introduce infection, and is never done in the field.

17. Peritonitis can lead to shock mainly by:

    1. A. Fluid shifting into the abdomen and sepsis
    2. B. Raising blood pressure from intense pain
    3. C. Causing direct bleeding from the bowel wall
    4. D. Paralyzing the diaphragm and the lungs
    Show answer

    Answer: A. Fluid shifting into the abdomen and sepsis

    Inflamed peritoneum leaks large volumes of fluid into the abdomen (third spacing), and bacterial infection progresses to septic shock. Pain may raise blood pressure briefly but does not cause shock.

18. A man reports abdominal pain after being struck, and he has blood in his vomit. This finding suggests injury to the:

    1. A. Kidney or ureter
    2. B. Bladder or the urethra
    3. C. Spleen or pancreas
    4. D. Stomach or duodenum
    Show answer

    Answer: D. Stomach or duodenum

    Hematemesis after trauma points to bleeding into the upper gastrointestinal tract from the stomach or duodenum. Kidney, ureter, and bladder injuries produce hematuria rather than bloody vomit.

19. A 25-year-old with a gunshot wound to the lower abdomen has bright red blood from the rectum. This finding suggests:

    1. A. A rectal or lower bowel injury
    2. B. A bleeding ulcer in the duodenum
    3. C. An isolated bladder rupture
    4. D. A splenic laceration
    Show answer

    Answer: A. A rectal or lower bowel injury

    Fresh rectal bleeding after penetrating trauma points to a wound of the rectum or colon, which carries a high risk of fecal contamination. Upper gastrointestinal bleeding usually causes dark, tarry stool rather than bright red blood.

20. Which statement about pain medication in a patient with a suspected hollow organ injury is correct?

    1. A. Analgesia hides the signs of peritonitis
    2. B. Opioids are banned in abdominal trauma
    3. C. Appropriate analgesia is safe and humane
    4. D. Analgesia must wait until after surgery
    Show answer

    Answer: C. Appropriate analgesia is safe and humane

    Current evidence shows that judicious opioid analgesia does not mask the surgical diagnosis, so pain should be treated per protocol. Withholding analgesia to preserve the exam is an outdated practice.

21. A patient with a bowel injury who is not treated may develop sepsis because:

    1. A. The spleen stops filtering the blood
    2. B. Bacteria spread from the peritoneum
    3. C. The kidneys cease producing urine
    4. D. The liver stops making clotting factors
    Show answer

    Answer: B. Bacteria spread from the peritoneum

    Bacteria from the bowel lumen multiply in the peritoneal cavity and enter the bloodstream, causing a systemic response. Kidney and liver dysfunction are consequences of sepsis, not its cause.

22. A 34-year-old with a lap-belt injury has had abdominal pain that steadily worsened over 3 hours during a long transport, with rising heart rate. Which action is most appropriate?

    1. A. Stop reassessing to let him rest quietly
    2. B. Assume pain from the belt bruise and continue
    3. C. Give oral fluids for possible dehydration
    4. D. Reassess often and update the hospital
    Show answer

    Answer: D. Reassess often and update the hospital

    Worsening pain and tachycardia over time suggest evolving peritonitis or bleeding, and the receiving team should be warned so they can prepare. Oral fluids are withheld because surgery is likely and vomiting with aspiration is a risk.

23. A man has a broom handle impaled in his rectum after an assault and is bleeding slightly from the anus. The correct field care is to:

    1. A. Stabilize it in place and transport
    2. B. Pull it out gently to stop the pain
    3. C. Push it farther in to stop bleeding
    4. D. Cut it off flush with the skin now
    Show answer

    Answer: A. Stabilize it in place and transport

    As with any impaled object, a rectal foreign body is left in place, stabilized with bulky dressings, and removed in the hospital, where perforation of the rectum or colon can be managed. Pulling it out may tear the bowel or cause bleeding, pushing it deeper adds injury, and cutting it flush makes removal harder. Provide privacy and consider assault reporting rules.

24. After blunt trauma to the left upper abdomen, you hear bowel sounds over the left lower chest. This finding suggests:

    1. A. A left tension pneumothorax
    2. B. Diaphragmatic rupture
    3. C. A normal finding in thin adults
    4. D. A perforated stomach below
    Show answer

    Answer: B. Diaphragmatic rupture

    A torn diaphragm lets the stomach or bowel herniate into the chest, where bowel sounds may be heard and breathing is impaired. A tension pneumothorax causes absent breath sounds, not bowel sounds.

25. After a steering-wheel blow to the upper abdomen, which hollow organ can perforate with few early peritoneal signs because most of it lies in the retroperitoneum?

    1. A. Stomach
    2. B. Transverse colon
    3. C. Duodenum
    4. D. Gallbladder
    Show answer

    Answer: C. Duodenum

    Most of the duodenum (its second to fourth parts) lies behind the peritoneum against the spine, so a direct epigastric blow from a steering wheel or handlebar can crush or burst it while its contents leak into the retroperitoneum rather than the peritoneal cavity. Early signs are vague upper abdominal or back pain, and peritonitis may not appear for hours, which is why mechanism matters. The stomach is intraperitoneal, and its acid produces rapid, obvious peritoneal signs. The transverse colon hangs within the peritoneal cavity on its mesentery, so a perforation spills into the peritoneum. The gallbladder lies under the liver inside the peritoneum, and leaked bile causes chemical peritonitis. (ATLS 10th ed., duodenal injury; Caroline 9th ed., hollow organ injury.)