How to Treat a Stab Wound to the Stomach

A stab wound to the stomach is a surgical emergency that demands immediate professional medical care. If you are with someone who has been stabbed in the abdomen, calling emergency services is the single most important thing you can do. While waiting for help, there are a few things a bystander can do that genuinely improve the person’s chances, and a few common mistakes that make things worse. But the real treatment happens in a hospital, where surgeons decide whether to operate and how to repair the damage inside.

What a Bystander Can Do Right Now

If someone has been stabbed in the abdomen and you are the first person on the scene, the priorities are simple: stop the bleeding you can see, protect what should be inside the body, and get professional help moving toward the patient.

Call emergency services first. Then turn your attention to the wound. If there is external bleeding, apply firm, steady pressure with a clean cloth or piece of clothing. Do not lift the cloth to check whether the bleeding has stopped; just keep pressing and add more material on top if blood soaks through. If the knife or object is still embedded in the body, leave it in place. Removing it can cause far more bleeding than leaving it alone, because the object may be plugging a damaged blood vessel.

If abdominal contents have come out through the wound, a situation called evisceration, do not try to push them back inside. Military and civilian trauma guidelines are clear on this point: forcing organs back into the abdomen risks contamination, further tissue damage, and worsening of internal bleeding. Instead, cover the exposed tissue with a moist, clean covering. A damp cloth or plastic wrap works if nothing else is available. Keeping the tissue moist is critical because exposed bowel dries out quickly and begins to die. If you can find clear plastic wrap, that is actually preferred by trauma teams because it lets medics see what is happening underneath without removing the dressing.¹

Keep the person lying flat and as still as possible. If they are conscious, talking to them and keeping them calm helps slow their heart rate, which reduces blood loss. Do not give them anything to eat or drink; if surgery is needed, a full stomach complicates anesthesia.

What Happens at the Emergency Department

Once the patient reaches the hospital, the trauma team works fast to figure out two things: is the person losing blood internally, and has the wound reached deep enough to damage organs? The physical exam comes first. Doctors check for signs of internal bleeding like a falling blood pressure or a rigid, tender abdomen. They also look for peritonitis, which is inflammation of the abdominal lining that signals bowel contents have leaked into the body cavity.

Contrast-enhanced CT scanning is the primary imaging tool for penetrating abdominal injuries. It picks up damage to solid organs like the liver and spleen as well as injuries to hollow organs like the intestines with high accuracy.² Ultrasound also plays a role, particularly for detecting free fluid in the abdomen, which suggests internal bleeding. A specialized ultrasound protocol for stab wounds showed perfect sensitivity for catching injuries in one study, though its usefulness depends on the skill of the person performing it.³ A separate study looking at ultrasound for detecting whether a stab wound had actually penetrated the abdominal wall found its sensitivity was only about 59%, improving with more experienced operators.⁴

For wounds to the back or flank, the diagnostic approach shifts somewhat. A triple-contrast CT scan, which uses contrast given intravenously, by mouth, and rectally, has been shown to catch all injuries requiring surgery, with very high specificity.⁵ Flank wounds are trickier because the thick muscles of the back can mask internal damage, and the kidneys and colon sit in that region without much protection.

Not Every Stab Wound Needs Surgery

One of the biggest shifts in trauma care over the past several decades is the recognition that mandatory surgery for every abdominal stab wound does more harm than good. Before the 1960s, every penetrating wound to the abdomen meant an automatic trip to the operating room. Surgeons eventually realized that many stab wounds do not actually damage any internal organs, and opening someone up to check carries its own serious risks, including infection, prolonged recovery, and hernias at the incision site.

Today, the approach is called selective nonoperative management. If a patient arrives with stable blood pressure, no signs of peritonitis, and no organs protruding from the wound, the trauma team can often observe the patient closely instead of operating. A large systematic review of this approach found that about 86% of patients selected for observation did not end up needing surgery at all, and there were zero reported deaths among those managed without an operation.⁶ Patients who went straight to surgery, by contrast, tended to stay in the hospital longer and had more complications.

That said, some situations demand immediate surgery. Three clinical findings at the initial assessment trigger an emergency operation: hemodynamic instability (the patient’s blood pressure is crashing despite fluids), peritonitis (the abdomen is rigid and exquisitely tender, suggesting bowel contents have spilled), and evisceration (organs are visible outside the body).⁷ In one study, about 42% of patients with penetrating abdominal stab wounds needed immediate surgery on arrival, and among those with visible organ protrusion, roughly 78% had actual organ damage confirmed during the operation.⁸

What Surgeons Actually Do During the Operation

When surgery is needed, the standard approach is an exploratory laparotomy: a long incision down the middle of the abdomen that gives the surgeon a full view of everything inside. The goal is to find every injury, stop all bleeding, and repair or remove damaged tissue. For stomach injuries specifically, the repair is usually straightforward. The hole is stitched closed in layers, and a South African study of penetrating gastric injuries found that all cases were successfully treated with this kind of primary repair, with no failures of the suture line.⁹

When multiple organs are damaged and the patient is in severe shock, surgeons may use a staged strategy called damage control surgery. Rather than trying to fix everything at once, the first operation focuses only on stopping life-threatening bleeding and containing any bowel spillage. The abdomen is then temporarily left open, often using a vacuum-assisted dressing system that helps manage swelling and fluid.¹⁰ The patient goes to intensive care for stabilization, and the surgical team returns within a day or two to complete the definitive repairs. For severe liver injuries managed this way, returning to the operating room within 48 hours has been shown to be feasible and effective.¹¹

In recent years, some trauma centers have started using laparoscopic surgery (operating through small incisions with a camera) for patients who are hemodynamically stable. This approach causes less tissue disruption, and early evidence suggests it leads to less postoperative pain, shorter recovery, and fewer complications compared with a full open laparotomy.¹² It is not appropriate for unstable patients or those with multiple organ injuries, but for the right candidate, it represents a real improvement in recovery experience.

The Tricky Zone Between the Chest and Abdomen

Stab wounds to the lower chest, roughly from the nipple line down to the bottom of the rib cage, pose a particular diagnostic challenge. This region is called the thoracoabdominal zone, and a knife entering here can damage the diaphragm, the muscular sheet that separates the chest from the abdomen. A diaphragm injury is easy to miss because it may produce no immediate symptoms, but if left unrepaired, abdominal organs can gradually herniate up into the chest cavity, causing serious problems weeks or months later.

Standard imaging misses a significant number of these injuries. In one study of 55 patients with left-sided penetrating thoracoabdominal trauma, 40% had diaphragmatic injuries, but only about 39% of those with positive findings on imaging actually had a diaphragm tear.¹³ Diagnostic laparoscopy, where a camera is inserted through a small incision to directly inspect the diaphragm, is considered the gold standard for catching these hidden tears.¹⁴ The good news is that once found, most diaphragm injuries can be repaired laparoscopically without converting to a full open procedure. In the study mentioned above, over 95% of confirmed tears were successfully fixed through the scope.¹³

This is one of those areas where the location of the wound changes the entire treatment plan. A wound two inches higher or lower can mean the difference between straightforward observation and a mandatory scope procedure to check for hidden damage. If you are describing a wound location to emergency dispatchers, being as specific as possible about where on the torso the wound sits genuinely helps the receiving team prepare.

Fluid Resuscitation and Why Less Can Be More

A natural instinct when someone is losing blood is to replace that volume as aggressively as possible. For decades, trauma protocols did exactly that, pumping large volumes of IV fluids into patients to keep their blood pressure up. The thinking has shifted. Current guidelines favor a strategy called permissive hypotension, which means accepting a blood pressure somewhat below normal while the bleeding source has not yet been surgically controlled.¹⁵

The reasoning is counterintuitive but makes sense once you think about it. Aggressively pushing blood pressure back to normal levels before the bleeding has been stopped can actually dislodge the blood clots the body is trying to form, worsening the hemorrhage. Limiting fluid resuscitation keeps the pressure low enough for clots to hold while still maintaining enough circulation to keep vital organs alive. This approach appears especially beneficial for penetrating injuries where there is a single bleeding site, like a stab wound, rather than blunt trauma with multiple diffuse injuries.

Preventing Infection After Abdominal Injuries

Infection is one of the most common complications after a penetrating abdominal wound, particularly when the bowel has been punctured. A hole in the intestine leaks bacteria-laden contents into the normally sterile abdominal cavity, creating a setup for peritonitis and abscess formation. Antibiotic protocols for abdominal trauma follow a tiered approach based on what was damaged and how quickly it was repaired.

If no hollow organ was injured, meaning the knife hit only solid tissue or fat, no additional antibiotics beyond the initial dose are needed. If a bowel injury is found and repaired within 12 hours, antibiotics are continued for no more than 24 hours. If repair takes longer than 12 hours, antibiotics may be extended up to 7 days. They go beyond 7 days only when the bowel repair is incomplete or the patient shows ongoing signs of infection.¹⁶ These guidelines reflect the understanding that prolonged antibiotic courses create their own problems, including antibiotic-resistant infections and disruption of the gut’s normal bacterial environment.

Another serious complication, particularly in patients whose abdomen has been left temporarily open after damage control surgery, is abdominal compartment syndrome. This occurs when pressure inside the abdominal cavity rises high enough to compress organs and restrict blood flow. When it develops, the treatment is surgical decompression, essentially reopening the abdomen to relieve the pressure. Negative-pressure wound therapy is commonly used to manage the open abdomen afterward.¹⁷

Recovery After Abdominal Stab Wound Surgery

How quickly someone recovers depends heavily on which organs were injured, whether the surgery was open or laparoscopic, and whether complications like infection developed. A person whose wound did not require surgery and was successfully managed with observation may leave the hospital within a few days. Someone who needed a full open laparotomy can expect a hospital stay of a week or more, followed by several weeks of restricted activity at home.

Open laparotomy carries specific long-term risks. Surgical site infections are common, and incisional hernias, where tissue pushes through the healing surgical wound, affect a meaningful percentage of patients over the months and years following surgery. Prolonged ileus, a temporary shutdown of normal bowel movement, frequently delays recovery and can keep patients in the hospital longer than the injury itself would. These complications are a major reason trauma surgeons have become more conservative about operating when the clinical picture allows for observation instead.

For patients who do well in the initial recovery, most can return to normal activities within a few months. Physical therapy and gradual increases in activity help prevent deconditioning and support abdominal wall healing. Psychological recovery can take longer. Post-traumatic stress, anxiety about the event, and difficulty sleeping are common after violent injuries, and mental health support should be considered a standard part of the recovery plan, not an afterthought.

Why Wound Documentation Matters More Than You Think

Because stab wounds are almost always the result of assault or self-harm, the medical record becomes a legal document. Accurate documentation of wound location, size, shape, depth, and direction is essential for criminal investigations, court proceedings, and the patient’s own future medical care. Despite this, research has found that wound documentation in emergency departments is often poor, regardless of the hospital’s level of care.¹⁸

For patients and their families, this has practical implications. If you are able to, take note of details before they are lost: the time the injury occurred, whether anything was removed from the wound before paramedics arrived, whether the patient lost consciousness, and approximately how much blood was visible at the scene. Trauma teams appreciate this information, and it can influence treatment decisions. From a legal standpoint, if wound documentation is incomplete, it can complicate the prosecution of an assailant or the assessment of an insurance claim. Advocating for thorough documentation, even in the chaos of an emergency department, protects the patient’s interests in more ways than one.