Hollow visceral injuries are far less common in blunt abdominal trauma than in penetrating abdominal trauma. From 1982 through 1993 we treated 50 patients with 57 major blunt injuries to the gut, defined as perforation, transection, or devascularization. Thirty-two patients (64%) were injured in motor vehicle collisions. Of these, 29 wore no restraints; three were wearing lap belts (none wore lap-shoulder restraints). Mean injury Severity Score (ISS) in patients wearing lap belts was 13.3, compared with 28.6 in the 29 patients who were not using restraint devices (P < 0.01). Small bowel perforations were the most frequent injuries, followed by devascularization of the small bowel, colorectal injuries, duodenal, and gastric perforations. ISS and mortality rates were lowest in small bowel injuries and higher in the less common colonic and gastroduodenal injuries. Except for those patients with perforations of the small bowel, most patients had associated injuries to the head, chest, or abdominal solid organs that were largely responsible for morbidity and mortality. Injuries to the abdominal hollow viscera are unusual following blunt trauma, but are the result of very high energy truncal trauma, and are associated with multiple additional injuries. Most alert patients had physical findings suggestive of peritoneal irritation, but when diagnostic testing was necessary, peritoneal lavage was superior to computed tomography scanning (false negatives = 6.7% versus 36%, respectively; P < 0.05). A high index of suspicion is necessary to avoid diagnostic delays that can lead to severe complications and death.