The Management of Blunt Abdominal Trauma Patients with Computed Tomography Scan Findings of Free Peritoneal Fluid and No Evidence of Solid Organ Injury

Abstract

Modalities available for the diagnosis of blunt abdominal traumatic (BAT) injuries include focused abdominal sonography for trauma, diagnostic peritoneal lavage, and computed tomography (CT) of the abdomen/pelvis. Hollow viscous and/or mesenteric injury (HVI/MI) can still be challenging to diagnose. Specifically, there is debate as to the proper management of BAT when CT findings include free peritoneal fluid but no evidence of solid organ injury (SOI). Our objective was to determine the incidence of HVI/MI and to evaluate the management of BAT patients with CT findings of peritoneal fluid without evidence of SOI. An Institutional Review Board-approved retrospective chart review was conducted of all BAT patients with peritoneal fluid on CT admitted to Kern Medical Center from January 1, 2003 to July 31, 2004. A total of 2651 trauma admissions yielded 79 patients. Fourteen of these had no evidence of SOI. Nonoperative management was successful in only 2 of these 14, whereas 12 required an operation, with 11 being therapeutic. Trigger to operate and time from presentation to laparotomy was hypotension in three patients (164 minutes), signs of HVI/MI on CT in two patients (235 minutes), diaphragm injury on CT in one patient (95 minutes), and for peritoneal signs in six patients (508 minutes). In BAT patients with peritoneal fluid on CT without evidence of SOI, there should be a high suspicion of HVI/MI. Relying on increasing abdominal tenderness to trigger laparotomy can result in delayed treatment.

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References

Livingston

D.H.

, Lavery

R.F.

, Passannante

M.R.

Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy.

Am J Surg 2001; 182: 6–9.

Brasel

K.J.

, Olson

C.J.

, Stafford

R.E.

Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma.

J Trauma 1998; 44: 889–92.

A.K.T.

, Simons

R.K.

, Kirkpatrick

A.W.

Intra-abdominal free fluid without solid organ injury in blunt abdominal trauma: an indication for laparotomy. Poster presentation at the 60th Annual Meeting of the American Association for the Surgery of Trauma, San Antonio, TX, October 11–15, 2000.

Levine

C.D.

, Patel

U.J.

, Wachsberg

R.H.

CT in patients with blunt abdominal trauma: clinical significance of intraperitoneal fluid detected on a scan with otherwise normal findings.

AJR 1995; 164: 1381–5.

Rodriguez

, Barone

J.E.

, Wilbanks

T.O.

Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systemic review of incidence and management.

J Trauma Injury Infect Crit Care 2002; 53: 79–85.

Rodriguez

Recognition of intra-abdominal injury in blunt trauma victims. A prospective study comparing physical examination with peritoneal lavage.

Am Surg 1982; 48: 457–9.

Sherman

H.F.

, Young

J.S.

, Bowling

Nonoperative management of blunt hepatic injuries: safe at any grade?

J Trauma 1994; 37: 616–21.

Croce

M.A.

, Federle

, Billiar

T.R.

Nonoperative management of blunt hepatic trauma is the treatment of choice for thermodynamically stable patients. Results of a prospective trial.

Ann Surg 1995; 221: 744–55.

Townsend

M.C.

Diagnostic laparoscopy as an adjunct to selective conservative management of solid organ injuries after blunt abdominal trauma.

J Trauma 1993; 35: 647–53.

10.

Chandler

C.F.

Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury.

Am Surg 1997; 63: 885–8.

11.

Eanniello

V.C.

, Gabram

S.G.A.

, Eusebio

Isolated free fluid on abdominal computerized tomographic scan: an indication for surgery in blunt trauma patients?

Conn Med 1994; 58: 707–10.

12.

Jackson

B.C.

, O'Callaghan

T.A.

, Lynsky

D.D.

The dilemma of free fluid on abdominal computerized tomography in blunt trauma.

Crit Care Med 2000; 28: SA141.

13.

Hulka

, Mullins

R.J.

, Leonardo

Significance of peritoneal fluid as an isolated finding on abdominal computed tomographic scans in pediatric trauma patients.

J Trauma 1998; 44: 1069–72.

14.

Cunningham

M.A.

, Tyroch

A.H.

, Kaups

K.L.

Does free fluid on abdominal computed tomographic scan after blunt trauma require laparotomy?

J Trauma 1998; 44: 599–603.

15.

Shreck

, Shatney

, Sensaki

The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation.

Am J Surg 1994; 168: 670–5.

16.

Meyer

D.M.

, Thal

E.R.

, Weigelt

J.A.

Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma.

J Trauma 1989; 29: 1168–72.

17.

Ceraldi

C.M.

, Waxman

Computerized tomography as an indicator of isolated mesenteric injury: a comparison with peritoneal lavage.

Am Surg 1990; 56: 806–10.

18.

Boulanger

B.R.

, McLellan

B.A.

, Brenneman

F.D.

Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma.

J Trauma 1996; 40: 867–74.

19.

Richards

J.R.

, McGahan

J.P.

, Simpson

J.L.

Bowel and mesenteric injury: evaluation with emergency abdominal ultrasound.

Radiology 1999; 211: 399–403.

20.

Malhotra

A.K.

, Fabian

T.C.

, Katsis

S.B.

Blunt bowel and mesenteric injuries: the role of screening computed tomography.

J Trauma 2000; 48: 991–1000.

21.

Soyka

J.M.

, Martin

, Sloan

E.P.

Diagnostic peritoneal lavage: is an isolated WBC count ≥500/mm³ predictive of intraabdominal injury requiring celiotomy in blunt trauma patients?

J Trauma 1990; 30: 874–9.

22.

Yasuhiro

, Hiroshi

, Kunihiro

New diagnostic peritoneal lavage criteria for diagnosis of intestinal injury.

J Trauma Injury Infect Crit Care 1998; 44: 991–8.

23.

Alyono

Significance of repeating diagnostic peritoneal lavage.

Surgery 1982; 91: 656–59.