abdominaltrauma diagnostik

7/29/2019 Abdominaltrauma Diagnostik

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Review Article

Actual Diagnostic Strategiesin Blunt Abdominal TraumaPaul L.O. Broos1, Herbert Gutermann2

European Journal of Trauma 2002 No. 2 Urban& Vogel

European Journal of Trauma

AbstractAn accurate assessment of patients with potentialblunt abdominal trauma should include a safe and reli-able method of determining the need for operativeintervention because the mortality and morbidity ofthese injuries are directly dependent on the immedi-ately valid diagnostic work-up. Since peritoneal signs

are often subtle, overshadowed by pain from associat-ed injury or masked by head trauma and intoxicants,clinical methods of diagnosis are often unreliable.Since the frequently injured liver and spleen are nowa-days more frequently managed nonoperatively, anacute assessment not only of the presence of injury,but also of the nature and extent of the injuries to theintraabdominal organs, raises an increasing demand ofboth sensitive and specific diagnostic modalities.

This article discusses the use of different diagnosticmodalities including peritoneal lavage, computed

tomography scanning, ultrasound and laparoscopy inthe diagnosis and immediate management of bluntabdominal trauma patients, and formulates a traumaprotocol for managing these patients.

Key WordsBlunt abdominal trauma Diagnostic procedures

Eur J Trauma 2002;28:6474

DOI 10.1007/s00068-002-1155-6

IntroductionAssessment of abdominal injury must be prioritized rel-

ative to concomitant injuries. Morbidity and mortality

will depend on the extent and nature of the injury, but to

an equal extent on the timely use of adequate diagnostic

procedures and vigorous therapy directed at immediate

life-threatening problems. The ultimate goal is to

reduce morbidity and mortality resulting from abdomi-

nal trauma through an organized plan of assessment and

resuscitation. This assessment must focus on determin-

ing the need for early surgical therapy in unstable

patients, and then be directed to the diagnosis of specif-

ic organ injury in stable patients [1].

An accurate and rapid diagnosis of blunt abdominal

trauma requires knowledge of the currently available

diagnostic modalities, their indications and contraindi-

cations, and their advantages and pitfalls.

Physical examination remains the backbone of the

assessment of blunt abdominal injury. However, since

peritoneal signs are often subtle, overshadowed by pain

from associated injury, masked by head trauma and

intoxicants or anesthesia secondary to spinal cord

injury, clinical methods of diagnosis are often unreli-able.

Laboratory investigations and conventional radiol-

ogy are of limited use.

The goal of diagnostic peritoneal lavage (DPL) was

to establish the presence or absence of abdominal

lesions with higher accuracy, and to decrease the rate of

negative laparotomy results. However, often the bleed-

ing had stopped at laparotomy, or came from a source

not requiring surgery.

In the 1970s, computed tomography (CT) started to

fill the need for better diagnostic data in determining

the indications and timing for surgery. CT is a sensitiveand specific test for intraabdominal injury and has, in

part, fostered the nonoperative approach to certain

abdominal injuries. However, this examination is time-

1Department of Traumatology, and2Resident in Surgery, U.Z. Gasthuisberg, Leuven, Belgium.

Received: June 21, 2001; revision accepted: February 15, 2002


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Broos PLO, Gutermann H. Diagnostic Strategies in Blunt Abdominal Trauma

65European Journal of Trauma 2002 No. 2 Urban&Vogel

consuming, and in many centers the patient still has to

be transported from the resuscitation room to a distant

radiologic department.

For more than 30 years, there has been interest in

the use of ultrasound (US) for evaluating patients withblunt abdominal trauma [2]. With improved technology,

cost-effectiveness and extensive clinical experience, US

has emerged as the screening test of choice for blunt

abdominal trauma in most centers [13].

Laparoscopy is the latest modality to have found a

role in the evaluation and treatment of blunt abdominal

trauma. It can be used as an adjunct to CT in the nonop-

erative management of blunt abdominal trauma to eval-

uate the injury, detect occult lesions, and select patients

for nonoperative treatment. However, this approach is

so infrequently needed that at present, according to

general consensus, laparoscopy has a limited role in the

evaluation of blunt trauma [4].

Clinical ExaminationIn the literature, there is consensus about the unreliabil-

ity of initial abdominal examination following acute

blunt trauma [5, 6]. In a study on patients with blunt

abdominal trauma, Davis et al [7] reported that 43% of

their patients neither complained nor showed signs of

an intraabdominal injury. However, 44% of these cases

finally underwent laparotomy, of which 77% were qual-

ified as conclusive.Inspection for ecchymoses and abrasions may pro-

vide clues to internal hemorrhage. The seat-belt sign

(patterned bruising over the abdomen corresponding to

the position of the seat belt in vehicle occupants) is

often missed or misinterpreted. Epigastric ecchymoses

should arouse suspicion of duodenal, small bowel or

pancreatic lesions.

The physical findings most often associated with

internal injury are abdominal tenderness and muscular

defense, occurring in 75% of the patients with positive

findings. However, both liver and spleen injuries may

bleed very slowly, causing minimal peritoneal signs inthe first few hours after trauma. Peritoneal signs of

rebound tenderness and rigidity occur in only 28% of

the patients after intraperitoneal bleeding [8]. Some-

times, the only indication of intraabdominal bleeding

will be shock or postural hypotension. Nevertheless,

this hypotension at the scene or in transit to the hospi-

tal may be readily reversed by the infusion of crystal-

loids [9]. For this reason, the significant finding of

hypotension on admission may be masked and does

not contribute to the early diagnosis of intraabdominal

injuries.

Examination of the pelvis and perineum, and digital

rectal examination should be part of the routine assess-

ment after blunt trauma.Other clinical indications for possible intraabdomi-

nal lesions are:

1. macroscopic hematuria (odds ratio 3.62) [10],

2. pelvic fractures (odds ratio 1.5) [10],

3. fractures of the lower six ribs (20% chance of splenic

injury and 10% chance of hepatic injury) [8].

Given the unreliability of the clinical examination,

other diagnostic procedures are needed to assess the

presence and nature of abdominal injury. Nevertheless,

a full history and repeated physical examination remain

essential and may sometimes exclude intraabdominal

injury or determine the need for urgent surgery (i.e.,

presence of peritonitis) [1, 11, 12].

Laboratory InvestigationHematologic and blood chemistry values are of limited

use following blunt abdominal trauma, but baseline

tests are important because subsequent changes may be

the first sign of occult injury [5, 8].

Hematocrit reflects a balance of acute blood loss,

endogenous plasma refill, and administration of crystal-

loids [13]. Serial measurements are helpful in monitor-

ing continued hemorrhage, but they do not give anyinformation about the site of bleeding in the polytrauma

patient. A normal hemoglobin/hematocrit soon after

injury does not rule out intraabdominal hemorrhage, as

time is required for significant hemodilution.

Leukocytosis following trauma is common and gen-

erally nonspecific [2].

A rise in serum amylase suggests pancreatic injury,

but serum elevations are found not sooner than 3 h post

trauma and only in 7085% of all major pancreatic

injuries [14, 15]. Conversely, elevations also may occur

following trauma to the parotid gland, proximal small

bowel, and the genitourinary tract [16]. Reports on theefficacy of pancreatic isoamylase and lipase in evalua-

tion of blunt trauma victims have been equally disap-

pointing [1, 15, 17].

A rise in serum transaminase is nonspecific for liver

injury, and therefore not suitable as a diagnostic criteri-

on. However, serial measurements can be used in moni-

toring known liver injury [1, 3].

There still is an ongoing discussion in the literature

about other parameters for general screening, i.e.,


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C-reactive protein (CRP), lactate and base deficit [1, 10,

18] or other organ-specific parameters, i.e., bilirubin [3,

1921]. Their practical use in managing blunt abdominal

trauma, however, has not been determined yet.

Recent controversy has focused on the significanceof microscopic hematuria after blunt abdominal trau-

ma, particularly after insertion of a urinary catheter. In

the published literature, some authors believe that

screening urinalysis after blunt trauma should be omit-

ted. Only gross hematuria will mandate investigation of

the genitourinary tract [1, 2, 22]. At present, however,

prospective data are lacking to definitively exclude

screening urinalysis from the assessment of blunt trau-

ma victims.

Conventional Radiology

Radiographic examination should be done in the resus-

citation area of the emergency department, especially in

unstable patients.

Anteroposterior chest X-ray provides clues to asso-

ciated thoracic and diaphragmatic injury. It should be

done after gastric and tracheal tube placement to facili-

tate assessment of the mediastinum (i.e., deviation of

tracheal tube in case of aortic rupture) and to check the

placement. Intrathoracic positioning of the nasogastric

tube is often the first sign of a ruptured left diaphragm

[1, 2325]. Often free intraperitoneal air is also visible

on chest X-ray.A plain abdominal radiograph may show small

amounts of free intraperitoneal air in patients with gas-

tric, small bowel or colonic perforations [12, 15]. Free

retroperitoneal or mediastinal air may be caused by

duodenal rupture.

A search should be made for rib, pelvic, vertebral

body and transverse spinous process fractures, as these

warrant special consideration for nearby visceral dam-

age [2].

At least 800 ml of intraperitoneal blood is required

to be evident on plain abdominal radiograph [26]. With

extensive hemoperitoneum, the small bowel may floattoward the center of the abdomen with the production

of a ground-glass appearance. There may also be loss

of the psoas shadow or renal shadow in cases of

retroperitoneal hemorrhage [8].

However, in the trauma setting, the usefulness of

plain abdominal radiograph is rather limited, because in

most cases, it is not possible to perform the procedure in

the upright position, and most evidence for intraabdomi-

nal lesions (free air, ground glass) will be vague [2729].

A radiograph of the pelvis is indicated to look for

fractures, as these warrant special considerations for

nearby visceral damage.

A retrograde cystogram should be performed in

case of gross hematuria, or the presence of blood at theurethral meatus (before any attempt at urethral

catheterization). This may not only identify the cause of

the hematuria but also provide important information

whether an urgent laparotomy is mandatory in the set-

ting of free intraperitoneal bladder rupture [1, 2].

Before the emergence of CT, intravenous pyelography

(IVP) was widely used to assess renal injury after blunt

trauma [1]. CT is nowadays superior to IVP in the imag-

ing of renal injury, but IVP is inexpensive and can be

performed in the emergency or operating room. It pro-

vides quick information on the number of functioning

kidneys and allows identification of gross urine extrava-

sation.

Diagnostic Peritoneal LavageThe DPL was first described in 1965 by Root et al [30].

Their goal was to establish the presence or absence of

abdominal lesions with higher accuracy, and to decrease

the rate of negative laparotomy results.

Either by closed, open or semiopen technique a

catheter is introduced through the abdominal wall at the

level of the infraumbilical ring, and advanced into the

pelvic cavity [2, 8]. The closed technique is faster andeasier to learn but, although not demonstrated by the

literature, may be associated with a higher rate of iatro-

genic lesions [31]. The open technique is the most time-

consuming, but safer and certainly indicated in pregnan-

cy. A compromise is the semiopen technique: this

approach is rapid, safe, and reliable [8, 32, 33]. In

patients with a pelvic fracture, the DPL should be per-

formed above the umbilicus [1].

The initial tap is considered positive if > 10 ml of

blood, bile, bowel contents, or urine are aspirated. If, in

addition, the DPL fluid exits via a bladder catheter or

chest tube, the DPL is grossly positive. Otherwise, 1 l ofwarmed saline is infused. The aspirate is then analyzed

for red blood cell (RBC) count, which takes usually 30

min to obtain (> 100,000 RBC/mm3 is considered posi-

tive) [34].

Subsequent authors tried to improve detection of

specific injuries by the addition of a variety of addition-

al laboratory tests on the aspirated fluid, i.e., leukocytes,

amylase and Grams stain [8, 30, 35, 36]. The signifi-

cance of an isolated high white blood cell (WBC) count


66 European Journal of Trauma 2002 No. 2 Urban& Vogel


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67European Journal of Trauma 2002 No. 2 Urban& Vogel

in the lavage fluid, purposed to be an indicator of bowel

injury, has been repeatedly questioned. The clinical

experience indicates that a high proportion of such

patients will have nontherapeutic laparotomies [1, 37].

With the use of either open or closed technique inpatients with classic indications, complications from the

use of this technique have been extraordinarily rare,

with a complication rate of 15% [3841]. Relative con-

traindications to this procedure are late pregnancy,

gross obesity, and, according to some authors, previous

abdominal surgery [1, 8]. However, a study by Moore et

al [42] described no difference between patients with or

without previous surgery, in terms of complications of

DPL, positive and negative DPL rates, or false indica-

tions for laparotomy.

Several authors have studied the accuracy of DPL

[41, 4346]. Overall, they found a sensitivity ranging

from 94% to 100%, and a specificity from 84.2% to

100% (Table 1)

Although simple, relatively safe and cheap, there

are three major disadvantages associated with the use of

DPL: first of all, its oversensitivity and nonspecificity.

Only about 30 ml of blood in the peritoneal cavity is

needed to produce a microscopically positive lavage

[47]. Another disadvantage to the use of DPL is that the

commonly injured organs such as the spleen and liver

often cease bleeding after blunt abdominal trauma.

Laparotomy is therefore not alwaysnecessary after a positive peritoneal

lavage [26, 34].

The third disadvantage has been

DPLs failure to detect retroperi-

toneal and diaphragmatic injuries, as

well as bowel injuries if it is per-

formed within a few hours after

trauma [12, 24, 25, 42]. However, in

recent studies, some authors still rec-

ommend DPL when hollow viscus

injury is suspected on the basis of

mechanism or physical findings,since both US and CT often fail in its

detection (cfr. infra) [48, 49].

In the past, DPL was frequently

used in hemodynamically unstable

patients to rapidly answer the ques-

tion: Is there intraabdominal hemor-

rhage that requires urgent laparoto-

my? As will be discussed, in most

centers this question is at present

essentially answered by US. However, in unstable

patients with indeterminate US, DPL remains, in our

opinion, the diagnostic modality of choice (cfr. infra).

Computed TomographyCT scanning has been used for approximately 20 years

in the evaluation of stable patients with possible

intraabdominal injuries from blunt abdominal trauma.

Initially, CT scanning took more time than DPL,

and early scanners were not able to produce images of

the same quality enjoyed currently. As a result, CT scan-

ning suffered in early studies comparing the two tech-

niques [50, 51].

In 1996, Navarrete-Navarro et al [52] published a

study in which they directly compared CT scanning to a

multidisciplinary approach that included bedside US

and DPL at the discretion of the surgical team. In this

study, CT was found to have comparable accuracy in

diagnosing intraabdominal injury and was more cost-

effective. This was confirmed by several recent studies

on the use of CT in blunt abdominal trauma. Overall,

they found a sensitivity ranging from 97.2% to 100%, a

specificity ranging from 94.7% to 99%, and an accuracy

ranging from 94.7% to 99% (Table 2) [44, 46, 5355].

The indications for CT scanning (with administra-

tion of oral and intravenous contrast) are stated below

(Table 3). According to a recent study by Bhne et al

Reference No. of Sensitivity Specificity Accuracy PPV NPVsubjects (%) (%) (%)

Meredith et al [43] 165 97 99 98 94 99

Liu et al [44] 55 100 84.2 91.7 92.3 100

Mendez et al [45] 286 94 99 98 98 97

Arrillaga et al [46] 15 100 100 100 100 100

Table 1. Summary of evidence for the use of diagnostic peritoneal lavage (DPL) in blunt ab-dominal trauma. NPV: negative predictive value; PPV: positive predictive value.


Pietzman et al [53] 120 97.6 98.7 98.3 100 99

Liu et al [44] 55 97.2 94.7 94.7 97.2 93.6

Livingston et al [54] 2,299 99.63

Arrillaga et al [46] 233 100 99 99 95 100

Malhotra et al [55] 8,112 88.3a 99.4a 99.9a 53a 99.9a

afor blunt bowel and mesenteric injuries

Table 2. Summary of evidence for the use of computed tomography (CT) in blunt abdominal

trauma. NPV: negative predictive value; PPV: positive predictive value.


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[56], 68% of polytraumatized patients require CT for

diagnosis of nonabdominal injuries (e.g., craniocere-

bral, vertebral or thoracic injuries), thus stating CT scan

to be the first diagnostic modality of choice in all stable

polytraumatized patients.Other studies indicate that the accuracy of modern

CT scanning is sufficiently good that patients with a

normal CT scanning and a brief hospital observation

(< 24 h) with repeated abdominal examination, can be

safely discharged without adverse effect [54, 57]. Liv-

ingston et al [54], e.g., showed a negative predictive

value of CT in blunt abdominal trauma of 99.63%

(Table 2). A weakness of these studies, however, is the

lack of long-term follow-up, but in the short term, the

data are quite convincing. Therefore, these authors

mention CT as the first diagnostic modality of choice

in blunt abdominal trauma, thus avoiding unnecessary

admission.

The major advantage of CT scanning is that it can

give a good assessment of retroperitoneal organ injuries

and a complete visualization of the intraabdominal sol-

id organs. Since nowadays more known injuries to

spleen, liver, kidney, or pancreas are treated nonopera-

tively, CT makes an estimation of the degree of injury to

these organs possible, resulting in fewer negative

laparotomies or fewer surgery for insignificant injuries

[2, 3, 41, 51]. Certain studies indicate that there are sev-

eral CT criteria that can be used to guide the need foroperative management in liver and spleen injuries, espe-

cially any indications of injury to the vascular hilum or

active bleeding [41]. The CT scan of the abdomen then

has to be performed at regular intervals. The accuracy of

this procedure in detecting splenic and hepatic injuries

has been reported to be 95% in retrospective reviews

and to be 99% accurate in detecting renal injuries [51,

58].

The CT scan, however, has not been found as reli-

able in detecting hollow viscus injuries, pancreatic,

mesenteric or bladder injuries in the period immediate-

ly after injury [12, 48, 49, 51]. Multiple retrospectivereviews have identified signs diagnostic or suspicious of

hollow viscus injuries: bowel wall thickening, free fluid

without solid organ injury, free peritoneal air, streaking

of the mesentery, and extravasation of contrast [12, 59].

In their series, Richards et al [60] showed a sensitivity of

CT in the detection of bowel and mesenteric injury of

80%. One study, however, by Malhotra et al [55] stated

a sensitivity and negative predictive value of CT in the

detection of bowel and mesenteric injury of 88.3% and

99.9%, respectively (Table 2). One should be aware,

however, that isolated diaphragmatic, early pancreatic,

urinary bladder or bowel injuries can be missed by CT,

stressing the importance of repeated clinical examina-

tion [1, 2, 12, 41, 4749, 60].

Although the CT scan is a noninvasive procedure, it

is not without its own shortcomings.

Contraindications to the use of CT in abdominal

trauma include an obvious need for laparotomy, a long

delay before the scanner will be available, an uncoop-

erative patient in whom sedation or paralyzing agents

are contraindicated, and an allergy to contrast agents

[34]. A CT scan is absolutely contraindicated as long as

the patient is in a hemodynamically unstable condition.

In these conditions, DPL or US remain at present thediagnostic procedures of choice in determining intraab-

dominal lesions and the need for urgent laparotomy

[1, 2].

Additional handicaps are the need for experienced

radiographic personnel around the clock, and the fact

that in centers, which do not have fixed CT units adja-

cent to the emergency resuscitation room, patients still

have to be transported to a distant radiologic depart-

ment. However, with the development of portable CT

scanning devices, the examination can take place in the

resuscitation room, even with unstable patients, thus

gaining a lot of valuable time. If necessary, patients canbe brought from the emergency department directly to

the operating room. The imaging of the currently avail-

able portable devices is excellent, but they still have

longer scan times compared with those of the fixed

units [61]. However, technical improvements are being

developed, and in our opinion portable CT scanning

will be found in the resuscitation room of the future,

changing radically the assessment of polytraumatized

patients.



1. Abnormal initial US (free fluid or obvious organ damage)

2. Significant hematuria

3. Pelvic fractures4. Need for a long anesthesia for repair of other injuries

5. Delayed presentation of the patient after blunt trauma

6. Follow-up of a patient undergoing nonoperative management of aknown intraabdominal visceral injury

7. (All polytraumatized patients)a

8. (Every blunt abdominal trauma, thus avoiding unnecessary admission)a

astill under discussion

Table 3. Indications for computed tomography (CT) in blunt abdomi-nal trauma [2]. US: ultrasound.


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UltrasoundFor more than 30 years, there has been interest in the

use of US for evaluating patients with blunt abdominal

trauma [2, 62]. With improved technology, cost-effec-

tiveness and extensive clinical experience, US hasemerged as the screening test of choice for blunt

abdominal trauma in most centers [13, 48, 62].

US has indeed many advantages over DPL and CT

scanning as stated in Table 4.

Since it involves no hazard from radiation or con-

trast media, the procedure is particularly appealing for

pediatric trauma and pregnant women. Furthermore,

US can be done serially to reassess the patient [41].

US has gained its immense popularity because most

authors agree that the single, most important criterion

for laparotomy, the quick and easy demonstration of a

hemoperitoneum, is met [1, 3, 41, 63]. It is after all an

impressively rapid technique (< 3 min) providing almost

instant information, particularly in the patient with a

large hemoperitoneum. The literature describes a speci-

ficity, sensitivity and accuracy for free fluid ranging

from 98% to 100%, 81% to 92% and 96% to 99%,

respectively [41, 46, 48, 62, 6470] (Table 5).

However, if an intraabdominal injury does not

result in hemoperitoneum or visible organ injury, i.e.,

hollow visceral perforation, it may be missed on an ini-

tial scan. Therefore, some authors stated repetitive US

in case of negative results on initial examination [12]. Astudy by Richards et al [60] showed a sensitivity of US in

detecting blunt bowel or mesenteric injury of 58%.

However, in the group of patients with isolated bowel or

mesenteric injury, the sensitivity was only 44% on initial

scan.

Considering the poorer results for ultrasound local-

ization of injuries, CT will still be required for patients

being considered for conservative therapy [71]. Howev-

er, with the improvement of US

techniques in organ imaging, several

authors are convinced that in the

near future, follow-up imaging ofthese lesions will be accomplished

by repeat sonography, thus eliminat-

ing the routine use of serial CT scan-

ning [72].

An additional disadvantage of

US is the fact that it is operator-

dependent, and accuracy increases

with experience [41]. Indeterminate

sonograms were reported in 6.7%,

and were usually due to patient factors (i.e., obesity,

subcutaneous emphysema). In indeterminate US,

Boulanger et al. recommend CT scanning for further

diagnosis in stable patients, and in unstable patients the

use of DPL [68].

US should be performed in a standardized manner,

as to evaluate the entire abdomen without unnecessary

detailed organ examination, in the literature described

as FAST (focused assessment with sonography fortrauma). With the patient in the horizontal supine posi-

tion, the retrovesical space (pouch of Douglas), the sub-

hepatic space (Morisons pouch), and the perisplenic

region are examined for free fluid [3, 68, 73]. The pres-

ence of fluid at any of these three sites denotes a posi-

tive FAST. A recent international consensus conference

recommended that also examination of the pericardium

should be included in FAST [62].

1. Bedside capability (resuscitation can continue while sonography isdone)

2. No contrast agents3. No contraindications, except an urgent necessity for laparotomy (sig-

nificant obesity, widespread subcutaneous emphysema and excessivebowel gas are relative contraindications, as the images are compro-mised)

4. No ionizing radiation

5. In addition to the peritoneal cavity, the thorax, pericardium, andretroperitoneum can be examined

6. Noninvasive

7. More cost-effective

8. Rapid assessment of abdominal status

9. Suitable for unstable patients to guide the resuscitation team towardor away from laparotomy

10. No urinary or gastric catheters

11. Repeatable

Table 4. Advantages of ultrasound (US) over diagnostic peritoneal la-gave (DPL) and computed tomography (CT) scanning.


Boulanger et al. [64] 206 81 98 96 90 97

McKenney et al. [65] 1,000 88 99 97 94 98

Healey et al. [69] 796 88 98 98 72 99

Arrillaga et al. [46] 104 92 100 99 100 99

Dolich et al. [48] 2,576 86 98 97 87 98

Sirlin et al. [70] 1,047a 89a 98a 97a 61a 99a

ain women of reproductive age, where anechoic fluid isolated to the cul-de-sac was considered physiologic

Table 5. Summary of evidence for the use of ultrasound (US) in blunt abdominal trauma. NPV:negative predictive value; PPV: positive predictive value.


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However, a recent study by Sirlin et al [70] exam-

ined the importance of free fluid in women of reproduc-

tive age with trauma. They stated that anechoic fluid

isolated to the cul-de-sac and adjacent recesses should

be considered physiologic in this population, and doesnot require further evaluation or intervention in the

absence of other radiologic or clinical findings. By using

their hypothesis in 1,047 patients, they reported a sensi-

tivity, specificity and accuracy of 89%, 98%, and 97%,

respectively, and a negative predictive value of 99%

(Table 5).

Magnetic Resonance ImagingMagnetic resonance imaging (MRI) is extremely accu-

rate in anatomic definition of structural injury, but

today, logistic virtually eliminates its practical applica-

tion in the evaluation of acute abdominal trauma. Fur-

thermore, MRI has no major advantages over CT in the

evaluation of blunt abdominal injury, with one notable

exception. MRI can uniquely image the diaphragm in

coronal and sagittal planes, and therefore may be the

ancillary diagnostic procedure of choice in suspected

diaphragmatic rupture [1].

AngiographyAngiography of liver and spleen has gained more and

more importance over the past few years. An improved

visualization of the vascularization made conservativetreatment of larger parenchymal lesions possible [2, 3,

72]. During the same procedure, smaller (i.e., subcapsu-

lar) bleeding can be treated by embolization. Occasion-

ally, lumbar or pelvic arterial embolization is useful for

massive retroperitoneal or pelvic bleeding [2, 72].

In addition to potential complications associated

with the invasive nature of arteriographic studies (i.e.,

arterial thrombosis, allergic reactions to contrasts), the

disadvantages of abdominal arteriography in the acute

trauma setting are exactly the same as those associated

with CT: the need for specialized personnel and equip-

ment, the time required to complete the study, the needto transport the patient to a distant radiologic depart-

ment, and the costs.

Diagnostic LaparoscopyTogether with the current rise in laparoscopic tech-

niques in todays surgery, the place of laparoscopy in the

diagnosis of abdominal injury is evolving.

In theory, with the current equipment, every

abdominal organ can be thoroughly explored for injury,

and, if necessary, the procedure can be therapeutic as

well [47]. And since liver and spleen injuries can be

assessed for active bleeding, laparoscopy can be an

adjunct to the nonoperative treatment of these lesions

as well.However, in real trauma setting, the usefulness of

laparoscopy in the diagnosis of blunt abdominal trauma

is rather limited, due to time limitations, costs, and inva-

siveness of the procedure [3, 47, 74]. There still are limi-

tations to the visualization of all areas of the abdomen,

and several studies have documented missed bowel

injuries [1, 12, 75]. An additional disadvantage is the

need for general anesthesia, and there is evidence that a

CO2 pneumoperitoneum can increase intracranial pres-

sure, compromise intestinal circulation, and may be

detrimental to hypovolemic patients [47, 64, 76, 77].

Further research is nessessary, but for the time being,

extreme caution and extensive monitoring are manda-

tory if CO2 laparoscopy is used for diagnosis and treat-

ment of trauma victims with possible associated head

trauma. It seems premature to declare hemodynamic

instability an absolute contraindication for the applica-

tion of laparoscopy, but evidence for this situation is still

insufficient, and each individual situation must there-

fore be handled with optimal clinical expertise.

However, there may be a place for laparoscopy in

abdominal trauma if CT findings are inconclusive, or as

an intermediate step toward laparotomy in case of apositive DPL or CT, thereby reducing the number of

unnecessary laparotomies and decreasing hospitaliza-

tion.

An analysis of eleven reports on accuracy of diag-

nostic laparoscopy published by Leppniemi et al. stat-

ed an overall sensitivity of 94.1%, a specificity of 98.4%,

and an accuracy of 97.2 % [47]. Among the 355 cases,

there were six false-negative findings. Three were

caused by a splenic injury requiring subsequent splenec-

tomy. The other three missed injuries were a sealed per-

foration of the sigmoid colon, a transection of the mid-

body of the pancreas, and a central retroperitonealhematoma [47].

A prospective study by Elliott et al. showed a speci-

ficity of 100% and a sensitivity of 96% in predicting the

need for laparotomy after trauma. However, the sensi-

tivity for hollow organ lesions remained unsatisfactory

[78, 79].

The natural evolution of the role of laparoscopy in

trauma was to progress from the diagnostic to the ther-

apeutic arena. Examples included repair of diaphrag-




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matic laceration, suturing of gastrointestinal perfora-

tions, and hemostasis of low-grade hepatic and splenic

lacerations [4].

With the improvement of techniques and instru-

mentations, the appliance of abdominal wall retractorsystems instead of a pneumoperitoneum, and the

expansion of bedside laparoscopic procedures under

local anesthesia with miniscopes, it is likely that with

more controlled studies, laparoscopy will find its place

as an integral part of evaluating and treating patients

with blunt abdominal trauma [3, 4, 47].

Recommended Diagnostic Protocol for the

Management of Blunt Abdominal Trauma (Figure 1)Hemodynamically unstable trauma victims clinically

suspected of intraabdominal bleeding, should be

aggressively resuscitated and considered for immediate

surgery [1, 11]. In the unstable patient, US can confirm

Blunt abdominal trauma

Hemodynamically stable

CT scan

Observe

Laparatomy

Observe

Obvious evidence for laparotomyon physical examination

Potential for non-surgical management

Ultrasound Free peritoneal fluid? Appreciation of pleura,

retroperitoneum, and bladder

Consider other sources of bleeding Consider DPL for further monitoring

certainly if US is inconclusive

Need for laparotomy,based on US results (i.e.,extensive organ injury)

Indication for immediateextraabdominal surgery

DPL monitoring orrepeated perop. US

Ultrasound Free fluid or organ injury?

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Free fluid

No free fluid

No (or if USis inconclusive)

Figure 1. Flow chart for the diagnosis of blunt abdominal trauma. CT: computed tomography; DPL: diagnostic peritoneal lavage; US: ultrasound.


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the need for urgent laparotomy (presence of free fluid

or obvious solid organ damage), or it can direct atten-

tion away from the abdomen to other injuries that may

be causing hemodynamic instability (i.e., pelvic frac-

tures) [79]. During the same procedure, the pleura,retroperitoneum (i.e., kidneys), and bladder can be

examined for profuse bleeding. If US is indeterminate,

DPL remains, in our opinion, the diagnostic modality of

choice in unstable patients.

In hemodynamically stable patients, all the different

organ systems should be thoroughly investigated, since

isolated abdominal trauma is rare. Special considera-

tion should be given to central nervous system, thorax

and, of course, the abdomen.

However, the timing and appropriateness of the dif-

ferent diagnostic modalities in stable patients with

abdominal trauma is less definitive than in unstable

patients. We believe that the initial test of choice

remains the US, for diagnosis of free fluid or obvious

solid organ injury.

If US shows no obvious organ damage or free fluid,

the patient is admitted for further observation, since

additional CT scanning in those patients seldom has

clinical relevance (6.6% in a study by Bhne et al [56]).

However, some authors do recommend CT scanning in

all patients, stating that no further admission is neces-

sary in case of a negative scan [54, 57].

If the findings of US are abnormal, but do not war-rant immediate laparotomy, a CT is generally accepted

as diagnostic modality of choice for further diagnosis [3,

12, 41].

CT can give an excellent assessment of retroperi-

toneal organ injuries (i.e., pancreas and kidneys) and a

complete visualization of the intraabdominal solid

organs. Furthermore, US characterization of organ

injuries remains currently inadequate to select patients

for conservative therapy.

A CT scan should also be performed in any patient

who will be lost to physical examination, i.e., a long

anesthesia for fixation of orthopedic injuries [34].Even if CT scanning is inconclusive for abdominal

organ lesion, it remains a valuable guidance for further

investigations (i.e., Gastrografin passage, angiography,

MRI, laparoscopy). For example, if a duodenal rupture

is suspected on CT, oral contrast (Gastrografin) can be

used to confirm/deny the diagnosis.

Although the incidence of hollow viscus injury after

blunt trauma is low (16%), the consequences of missed

or delayed diagnosis are significant in the form of high

morbidity and mortality, if surgical therapy is delayed

[12, 48, 55]. Therefore a high index of suspicion and a

low threshold for obtaining confirmatory testing are

necessary to avoid delaying the diagnosis of hollow vis-

cus injury. For suspected occult bowel and mesentericinjury, we recommend an initial US examination, which,

if negative for free fluid, should be followed by serial

abdominal examinations and CT.

In our opinion, DPL in stable patients is only indi-

cated if CT scanning is not possible. A potential indica-

tion for DPL is the need for urgent therapy for extra-

abdominal lesions (i.e., neurosurgery) before

intraabdominal injuries are definitively excluded on CT

scanning. The DPL catheter can be left in the abdomen

for further monitoring during extraabdominal surgery.

However, since US of the abdomen is also possible in

the operating room during extraabdominal surgery, this

indication for DPL is controversial.

We believe that in the next decade, both CT and

DPL will be used even more selectively, rather than as

screening examinations, certainly if FAST is expanded

in the future to include comprehensive organ imaging

(i.e., three-dimensional sonography) [62]. However,

some authors do not agree with our vision. They even

mention CT scanning as the first diagnostic modality of

choice in polytraumatized patients, since 68% of these

patients require CT for diagnosis of other injuries (e.g.,

craniocerebral, vertebral or thoracic injuries) [56].Diagnostic laparoscopy has the potentials to

become a valid part of the initial workout of blunt

abdominal trauma. With the improvement of tech-

niques and instrumentations, and the expansion of bed-

side laparoscopic procedures under local anesthesia

with miniscopes, it is likely that with more controlled

studies, laparoscopy will find its place as an integral part

of evaluating and treating patients with blunt abdomi-

nal trauma [3, 4, 47].

References

1. Boulanger BR, McLellan BA. Blunt abdominal trauma. Emerg MedClin North Am 1996;14:15171.

2. Broos PLO. Diagnostic procedures in abdominal trauma. JEUR1992;5:13443.

3. Feussner H, Papaziogas W, Siewer JR. Moderne Diagnostik desstumpfen Bauchtraumas. Chirurg 1999;70:124654.

4. Ivatury RR, Zantut LF, Yelon JA. Laparoscopy in the new century.Surg Clin North Am 1999;79:12915.

5. Robertson C, Redmond AD. The management of major trauma.Oxford: Oxford University Press, 1991:7993.

6. Schurink GWH, Bode PJ, Van Luijt PA, Van Vugt AB. The value ofphysical examination in the diagnosis of patients with bluntabdominal trauma: a retrospective study. Injury 1997;28:2615.




10/11



7. Davis JJ, Cohn I, Nance FC. Diagnosis and management of bluntabdominal trauma. Ann Surg 1976;183:672.

8. McAnena OG, Moore EE, Marcx JA. Initial evaluation of thepatient with the blunt abdominal trauma. Surg Clin North Am1970;70:495515.

9. Fischer RP, Miller-Crotchet P, Reed RL. The hazards of nonopera-tive management in adults with blunt abdominal injury. J Trau-ma 1988;28:14459.

10. Cushing BM, Clark DE, Cobean R, Schenarts PJ, Rutstein LA. Bluntand penetrating trauma has anything changed? Surg ClinNorth Am 1997;77:1321.

11. Sayers RD, Bewes PC, Porter KM. Emergency laparotomy forabdominal trauma. Injury 1992;23:537.

12. Metzger J, Fle M von, Babst R, Harder F. Dnndarmverletzungenbeim stumpfen Bauchtrauma: ein diagnostisches Problem! SwissSurg 1995;1:2225.

13. Greenfield RH, Bessen HA, Henneman PL. Effect of crystalloidinfusion on hematocrit and intravascular volume in healthy nonbleeding subjects. Ann Emerg Med 1989;18:515.

14. Takishima T, Sugimoto K, Hirata M, Asari Y, Ohwada T, Kakita A.Serum amylase level on admission in the diagnosis of bluntinjury to the pancreas: its significance and limitations. Ann Surg1997;226:70.

15. Bouwman DL, Weaver DW, Walt AJ. Serum amylase and its isoen-zymes a clarification of their implications in trauma. J Trauma1984;24:5738.

16. Moore EE. Resuscitation and evaluation of the injured patints. In:Zuidema GG, Ballinger W, Rutherford R, eds. Management oftrauma. Philadelphia: Saunders, 1985:126.

17. Buechter KJ, Arnold M, Steele B, Martin L, Byers P, Gomez G, Zep-pra R, Augenstein J. The use of serum amylase and lipse in evalu-ation and managing blunt abdominal trauma. Am Surg1990;56:204.

18. Davis JW, Mackersie RC, Holbrook TL, Hoyt TL. Base deficit as anindicator of significant abdominal injury. Ann Emerg Med1991;20:842.

19. Henneman PL, Barr D, Marx JA. Urinary lactic dehydrogenase asa marker of renal injury in blunt trauma patients with hema-turia. Ann Emerg Med 1988;17:797.

20. Liebert H. Relevance of urinary enzyme determination for thediagnosis and follow-up of kidney injuries and secondary kidneydamage results of a prospective studie. Langenbecks Arch Chir1988;3:270.

21. Sahdev P, Garramone RR, Schwartz RJ, Steelman SR, Jacobs LM.Evaluation of liver function tests in screening for intra-abdomi-nal injuries. Ann Emerg Med 1991;20:838.

22. Cass AC. Urethral injury in the multiple-injured patient. J Trauma1984;29:9016.

23. MacFarlane R, Pollard S. Traumatic rupture of the diaphragm. Br JHosp Med 1987;37:41820.

24. Broos PLO, Rommens PM, Charlier H, et al. Traumatic rupture of

the diaphragm. Review of 62 successive cases. Int Surg1989;74:8892.

25. Broos PLO, Rommens PM, Charlier H, et al. Rupture of thediaphragm caused by blunt trauma. Unfallchirurg1989;92:41923.

26. Hill AC, Schecter WP, Trunkley DD. Abdominal trauma and indi-cations for laparotomy. In: Mattox KL, Moore EE, Feliciano DV,eds. Trauma. Norwalk: Appleton & Lange, 1988:40139.

27. Espinoza R, Rodriguez A. Traumatic and nontraumatic perfora-tion of hollow viscera. Surg Clin North Am 1997;77:1291.

28. Frick EJ, Pasquale MD, Cipolle MD. Small bowel and mesenteryinjuries in blunt trauma. J Trauma 1999;46:920.

29. Neugebauer H, Wallenboeck E, Hungerford M. Seventy cases of

injuries of the small intestine caused by blunt abdominal trau-ma: a retrospective study from 1970 to 1994. J Trauma1999;46:116.

30. Root HD, Hauser CW, McKinley RC, et al. Diagnostic peritoneallavage. Surgery 1965;57:633.

31. Troop B, Fabian T, Alsup B, Kudsk K. Randomized prospectivecomparison of open and closed peritoneal lavage for abdominaltrauma. Ann Emerg Med 1991;20:12902.

32. Moore JB, Moore EE, Markochick VJ, Rosen P. Diagnostic peri-toneal lavage for abdominal trauma: superiority of the opentechnique at the infraumbilical ring. J Trauma 1981;21:5702.

33. Rothenberg S, Moore EE, Marx JA, Moore FA, McCroskey BL. Selec-tive management of blunt abdominal trauma in children. Thetriage role of peritoneal lavage. J Trauma 1987;27:11016.

34. Feliciano DV. Diagnostic modalities in abdominal trauma. SurgClin North Am 1991;71:24156.

35. Marx JA, Moore EE, Bar-Or D. Peritoneal lavage in penetratinginjuries of the small bowel and colon injuries: the value ofenzyme determination. Ann Emerg Med 1983;12:6870.

36. Alyono D, Perry JF. Value of quantitative cell count and amylaseactivity of peritoneal lavage fluid. J Trauma 1981;21:3458.

37. Jacobs DG, Angus L, Rodriguez A. Peritoneal lavage white count:a reassessment. J Trauma 1990;30:60712.

38. Engrav LH, Benjamin CI, Strate RG, Perry JF jr. Diagnostic peri-toneal lavage in blunt abdominal trauma. J Trauma1975;15:8549.

39. Powell DC, Bivins BA, Bell RM. Diagnostic peritoneal lavage. SurgGynecol Obstet 1982;155:25764.

40. Falcone RE, Thomas B, Hrutkay L. Safety and efficacy of diagnos-tic peritoneal lavage performed by supervised surgical and emer-gency medicine residents. Eur J Emerg Med 1997;4:150.

41. Amoroso TA. Evaluation of the patient with blunt abdominaltrauma: an evidence based approach. Emerg Med Clin North Am1999;17:6375.

42. Moore GP, Alden AW, Rodman GH. Is closed diagnostic peritoneallavage contraindicated in patients with previous abdominal

surgery? Acad Emerg Med 1997;4:287.43. Meredith JW, Ditesheim JA, Stonehouse S, Wolfman N. Comput-

ed tomography and diagnostic peritoneal lavage. Complemen-tary roles in blunt trauma. Ann Surg 1992;58:448.

44. Liu M, Lee CH, Peng FK. Prospective comparison of diagnosticperitoneal lavage, computed tomographic scanning and ultra-sonography for the diagnosis of blunt abdominal trauma. J Trau-ma 1993;35:26770.

45. Mendez C, Gubler DK, Maier RV. Diagnostic accuracy of peri-toneal lavage in patients with pelvic fractures. Arch Surg1994;129:477.

46. Arrilaga A, Graham R, York JW, Miller R. Increased efficiency andcost-effectivness in the evaluation of the blunt abdominal trau-ma patient with the use of ultrasound. Am Surg 1999;65:315.

47. Leppniemi AK, Elliot DC. The role of laparoscopy in blunt

abdominal trauma. Ann Med 1996;28:4839.48. Dolich MO, McKenney MG, Varela JE, Compton RP, McKenney KL,

Cohn SM. 2576 ultrasounds for blunt abdominal trauma. J Trau-ma 2001;50:10812.

49. Xeropotamos NS, Nousias VE, Ioannou HV, Kappas AM. Mesen-teric injury after blunt abdominal trauma. Eur J Surg2001;167:1069.

50. Catre MG. Diagnostic peritoneal lavage versus abdominal com-puted tomography in blunt abdominal trauma: a review ofprospective studies. Can J Surg 1995;38:11722.

51. Bell C, Coleridge ST. A comparison of diagnostic peritoneal lavageand computed tomography (CT scan) in evaluation of the hemo-dynamically stable patient with blunt abdominal trauma. J


11/11



Emerg Med 1992;10:27580.52. Navarrete-Navarro P, Vazquez G, Bosch JM, Fernandez E, Rivera R,

Carazo E. Computed tomography vs clinical and multidisciplinaryprocedures for early evaluation of severe abdomen and chesttrauma a cost analysis approach. Intensive Care Med

1996;22:208.53. Pietzman A, Makaroun M, Slasky B, Ritter P. Prospective study ofcomputed tomography in initial management of blunt abdomi-nal trauma. J Trauma 1986;26:58592.

54. Livingstone DH, Lavery RF, Passannante MR, Skurnick JH, FabianTC, Fry DE, Malangoni MA. Admission or observation is not neces-sary after a negative abdominal computed tomography scan inpatients with suspected blunt abdominal trauma: results of aprospective, multi-institutional trial. J Trauma 1998;44:273.

55. Malhotra AK, Fabian TC, Katsis SB, Gavant ML, Croce MA. Bluntbowel and mesenteric injuries: the role of screening computedtomography. J Trauma 2000;48:9911000.

56. Bhne K-H, Zgel N, Mayr E, Huser H. Routineeinsatz vonAbdomensonographie und Oberbauch-CT beim Polytrauma.Chirurg 2001;72:438.

57. Brasel KJ, Borgstrom DC, Kolewe KA, Weigelt JA. Abdominal com-puted tomography scan as a screening tool in blunt trauma.Surgery 1996;120:780.

58. Federle M, Jeffrey RB. Hemoperitoneum studied by computedtomography. Radiology 1983;148:18792.

59. Brasel K, Olson CJ, Stafford RE, Johnson TJ. Incidence and signifi-cance of free fluid on abdominal computed tomographic scan inblunt trauma. J Trauma 1998;44:88992.

60. Richards JR, McGahan JP, Simpson JL, Tabar P. Bowel and mesen-teric injury: evaluation with emergency abdominal US. Radiology1999;211:399403.

61. Mirvis SE. Use of portable CT in the R Adams Cowley Shock Trau-ma Center. Surg Clin North Am 1999;79:131730.

62. Boulanger RB, Rozycki GS, Rodriguez A. Sonographic assessmentof traumatic injury. Surg Clin North Am 1999;79:1297316.

63. Hoffmann R, Nerlich M, Muggia-Sullam M. Blunt abdominal

trauma in cases of multiple trauma evaluated by ultrasonogra-phy: a prospective analysis of 291 patients. J Trauma 1992;32:452.

64. Boulanger BR, Brenneman FD, McLellan BA. A prospective studyof emergent abdominal sonography after blunt trauma. J Trau-ma 1995;39:325.

65. McKenney MG, Martin L, Lentz K, Lopez C, Sleeman D, Aristide G,Kirton O, Nunez D, Najjar R, Namias N, Sosa J. 1000 consecutiveultrasounds for blunt abdominal trauma. J Trauma1996;40:60712.

66. Huang MS, Liu M, Wu JK, Shih HC, Ko TJ, Lee CH. Ultrasonographyfor the evaluation of hemoperitoneum during resuscitation: asimple scoring system. J Trauma 1994;36:1737.

67. Nordenholz KE, Rubin MA, Gularte GG, Liang HK. Ultrasound inthe evaluation and management of blunt abdominal trauma.Ann Emerg Med 1996;29:35766.

68. Boulanger BR, Brenneman FD, Kirkpatrick AW. The indeterminateabdominal sonogram in multisystem blunt trauma. J Trauma

1998;45:526.69. Healey MA, Simons RK, Winchell RJ, Gosink BB, Casola G, Steele

JT, Potenza BM, Hoyt DB. A prospective evaluation of abdominalultrasound in blunt abdominal trauma: is it useful? J Trauma1996;40:875.

70. Sirlin CB, Casola G, Brown MA, Patel N, Bendavid EJ, Deutsch R,Hoyt DB. US of blunt abdominal trauma: importance of freepelvic fluid in woman of reproductive age. Radiology2001;219:22935.

71. Pearl WS, Todd KH. Ultrasonography for the initial evaluation ofblunt abdominal trauma: a review of prospective trials. AnnEmerg Med 1996;27:35361.

72. Knudson MM, Maull KI. Nonoperative management of solidorgan injuries. Surg Clin North Am 1999;79:135771.

73. Scalea TM, Rodriguez A, Chiu WC, Brenneman FD. Focusedassessment with sonography for trauma (FAST): results from aninternational consensus conference. JTrauma 1999;46:466.

74. Stafford RE, McGonigal MD, Weigelt JA, Johnson TJ. Oral contrastsolution and computed tomography for blunt abdominal trau-ma: a randomized study. Ann Surg 1999;134:622.

75. Leppaniemi AK, Eliott DC. The role of laparoscopy in bluntabdominal trauma. Ann Med 1996;28:483.

76. Holthausen UH, Nagelschmidt M, Troidl H. CO2 pneumoperi-toneum: what we know and what we need to know. World J Surg1999;23:794800

77. Moncure M, Salem R, Moncure K, Testaiuti M, Marburger R, Ye X,Brathwaite C, Ross SE. Central nervous system metabolic andphysiologic effects of laparoscopy. Am Surg 1999;65:16872.

78. Rossi P, Mullins D, Thal E. Role of laparoscopy in the evaluation ofabdominal trauma. Am J Surg 1993;166:70710.

79. Elliott DC, Rodriguez A. The accuracy of diagnostic laparoscopy intrauma patients: a prospective controlled study. Int Surg1998;83:294.

Correspondence AddressProf. Dr. Paul BroosDepartment of TraumatologyU.Z. GasthuisbergHerestraat 493000 LeuvenBelgiumPhone (+32/16) 34-4666, Fax 4614e-mail: [email protected]

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