patient also included a small bowel contusion, pancreatic head contusion, a focal area of aortic disruption (dissection) just inferior to the renal arteries, and a retroperitoneal hematoma FIGURE 103.11 Intraoperative photograph of a segment of small bowel of a 15-year-old boy who was a lap and shoulder belt–restrained back seat passenger in a motor vehicle collision Initial examination revealed ecchymosis below the umbilicus and significant tenderness upon palpation of the lower abdomen Findings at laparotomy included near transaction of the terminal ileum with devitalized tissue at the edges of the injury Children who are seriously injured because of physical abuse commonly have more than one site of trauma; some of the injuries can be occult, and others may have been inflicted at different times Abdominal injuries are usually inflicted by fists, feet, or small handheld objects and are rarely penetrating The diagnosis of blunt abdominal injury caused by battering is difficult to make unless a high index of suspicion for child abuse is maintained An important clue is often an implausible historical account for the seriousness of the injury As with abdominal trauma caused by other mechanisms, physical examination findings may not be obvious Laboratory analyses and abdominal CT may be necessary to confirm the diagnosis Severe injuries may present with obtundation and shock, abdominal distention, and tenderness Intra-abdominal injuries most commonly involve the liver and the spleen, as well as the pancreas–duodenum–jejunum region In all such cases in which child battering is suspected, a child protection consultant should be involved early