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European Journal of Trauma

Review Article

Actual Diagnostic Strategies in Blunt Abdominal Trauma


Paul L.O. Broos1, Herbert Gutermann2

Abstract An accurate assessment of patients with potential blunt abdominal trauma should include a safe and reliable method of determining the need for operative intervention because the mortality and morbidity of these injuries are directly dependent on the immediately valid diagnostic work-up. Since peritoneal signs are often subtle, overshadowed by pain from associated injury or masked by head trauma and intoxicants, clinical methods of diagnosis are often unreliable. Since the frequently injured liver and spleen are nowadays more frequently managed nonoperatively, an acute assessment not only of the presence of injury, but also of the nature and extent of the injuries to the intraabdominal organs, raises an increasing demand of both sensitive and specific diagnostic modalities. This article discusses the use of different diagnostic modalities including peritoneal lavage, computed tomography scanning, ultrasound and laparoscopy in the diagnosis and immediate management of blunt abdominal trauma patients, and formulates a trauma protocol for managing these patients. Key Words Blunt abdominal trauma Diagnostic procedures
Eur J Trauma 2002;28:6474 DOI 10.1007/s00068-002-1155-6

Introduction Assessment of abdominal injury must be prioritized relative 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 abdominal trauma through an organized plan of assessment and resuscitation. This assessment must focus on determining the need for early surgical therapy in unstable patients, and then be directed to the diagnosis of specific 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 contraindications, 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 unreliable. Laboratory investigations and conventional radiology 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 bleeding 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 sensitive and specific test for intraabdominal injury and has, in part, fostered the nonoperative approach to certain abdominal injuries. However, this examination is time-

1 2

Department of Traumatology, and Resident in Surgery, U.Z. Gasthuisberg, Leuven, Belgium.

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

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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 with blunt 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 nonoperative management of blunt abdominal trauma to evaluate 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 Examination In the literature, there is consensus about the unreliability 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 qualified as conclusive. Inspection for ecchymoses and abrasions may provide 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 in the first few hours after trauma. Peritoneal signs of rebound tenderness and rigidity occur in only 28% of the patients after intraperitoneal bleeding [8]. Sometimes, the only indication of intraabdominal bleeding will be shock or postural hypotension. Nevertheless, this hypotension at the scene or in transit to the hospital may be readily reversed by the infusion of crystalloids [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 assessment after blunt trauma. Other clinical indications for possible intraabdominal 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 Investigation Hematologic 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 crystalloids [13]. Serial measurements are helpful in monitoring continued hemorrhage, but they do not give any information 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 generally 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 the efficacy of pancreatic isoamylase and lipase in evaluation of blunt trauma victims have been equally disappointing [1, 15, 17]. A rise in serum transaminase is nonspecific for liver injury, and therefore not suitable as a diagnostic criterion. However, serial measurements can be used in monitoring 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 significance of microscopic hematuria after blunt abdominal trauma, particularly after insertion of a urinary catheter. In the published literature, some authors believe that screening urinalysis after blunt trauma should be omitted. 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 trauma victims. Conventional Radiology Radiographic examination should be done in the resuscitation area of the emergency department, especially in unstable patients. Anteroposterior chest X-ray provides clues to associated thoracic and diaphragmatic injury. It should be done after gastric and tracheal tube placement to facilitate 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 gastric, 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 damage [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 float toward 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 intraabdominal 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 the urethral 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 setting 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 imaging of renal injury, but IVP is inexpensive and can be performed in the emergency or operating room. It provides quick information on the number of functioning kidneys and allows identification of gross urine extravasation. Diagnostic Peritoneal Lavage The 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 and easier to learn but, although not demonstrated by the literature, may be associated with a higher rate of iatrogenic lesions [31]. The open technique is the most timeconsuming, but safer and certainly indicated in pregnancy. 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 performed 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 of warmed 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 positive) [34]. Subsequent authors tried to improve detection of specific injuries by the addition of a variety of additional laboratory tests on the aspirated fluid, i.e., leukocytes, amylase and Grams stain [8, 30, 35, 36]. The significance of an isolated high white blood cell (WBC) count

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essentially answered by US. However, in unstable in the lavage fluid, purposed to be an indicator of bowel patients with indeterminate US, DPL remains, in our injury, has been repeatedly questioned. The clinical opinion, the diagnostic modality of choice (cfr. infra). experience indicates that a high proportion of such patients will have nontherapeutic laparotomies [1, 37]. Computed Tomography With the use of either open or closed technique in CT scanning has been used for approximately 20 years patients with classic indications, complications from the in the evaluation of stable patients with possible use of this technique have been extraordinarily rare, intraabdominal injuries from blunt abdominal trauma. with a complication rate of 15% [3841]. Relative conInitially, CT scanning took more time than DPL, traindications to this procedure are late pregnancy, and early scanners were not able to produce images of gross obesity, and, according to some authors, previous the same quality enjoyed currently. As a result, CT scanabdominal surgery [1, 8]. However, a study by Moore et ning suffered in early studies comparing the two techal [42] described no difference between patients with or niques [50, 51]. without previous surgery, in terms of complications of In 1996, Navarrete-Navarro et al [52] published a DPL, positive and negative DPL rates, or false indicastudy in which they directly compared CT scanning to a tions for laparotomy. multidisciplinary approach that included bedside US Several authors have studied the accuracy of DPL and DPL at the discretion of the surgical team. In this [41, 4346]. Overall, they found a sensitivity ranging study, CT was found to have comparable accuracy in from 94% to 100%, and a specificity from 84.2% to diagnosing intraabdominal injury and was more cost100% (Table 1) effective. This was confirmed by several recent studies Although simple, relatively safe and cheap, there on the use of CT in blunt abdominal trauma. Overall, are three major disadvantages associated with the use of they found a sensitivity ranging from 97.2% to 100%, a DPL: first of all, its oversensitivity and nonspecificity. specificity ranging from 94.7% to 99%, and an accuracy Only about 30 ml of blood in the peritoneal cavity is ranging from 94.7% to 99% (Table 2) [44, 46, 5355]. needed to produce a microscopically positive lavage The indications for CT scanning (with administra[47]. Another disadvantage to the use of DPL is that the tion of oral and intravenous contrast) are stated below commonly injured organs such as the spleen and liver (Table 3). According to a recent study by Bhne et al often cease bleeding after blunt abdominal trauma. Laparotomy is therefore not always necessary after a positive peritoneal Table 1. Summary of evidence for the use of diagnostic peritoneal lavage (DPL) in blunt abdominal trauma. NPV: negative predictive value; PPV: positive predictive value. lavage [26, 34]. The third disadvantage has been Reference No. of Sensitivity Specificity Accuracy PPV NPV DPLs failure to detect retroperisubjects (%) (%) (%) toneal and diaphragmatic injuries, as Meredith et al [43] 165 97 99 98 94 99 well as bowel injuries if it is perLiu et al [44] 55 100 84.2 91.7 92.3 100 formed within a few hours after Mendez et al [45] 286 94 99 98 98 97 trauma [12, 24, 25, 42]. However, in Arrillaga et al [46] 15 100 100 100 100 100 recent studies, some authors still recommend DPL when hollow viscus injury is suspected on the basis of Table 2. Summary of evidence for the use of computed tomography (CT) in blunt abdominal mechanism or physical findings, trauma. NPV: negative predictive value; PPV: positive predictive value. since both US and CT often fail in its Reference No. of Sensitivity Specificity Accuracy PPV NPV detection (cfr. infra) [48, 49]. subjects (%) (%) (%) In the past, DPL was frequently used in hemodynamically unstable 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 patients to rapidly answer the quesLivingston et al [54] 2,299 99.63 tion: Is there intraabdominal hemorArrillaga et al [46] 233 100 99 99 95 100 rhage that requires urgent laparotoMalhotra et al [55] 8,112 88.3a 99.4a 99.9a 53a 99.9a my? As will be discussed, in most a centers this question is at present for blunt bowel and mesenteric injuries

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[56], 68% of polytraumatized patients require CT for diagnosis of nonabdominal injuries (e.g., craniocerebral, 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]. Livingston 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 solid organs. Since nowadays more known injuries to spleen, liver, kidney, or pancreas are treated nonoperatively, 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 several CT criteria that can be used to guide the need for operative management in liver and spleen injuries, especially 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 reliable in detecting hollow viscus injuries, pancreatic, mesenteric or bladder injuries in the period immediately after injury [12, 48, 49, 51]. Multiple retrospective reviews 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

Table 3. Indications for computed tomography (CT) in blunt abdominal trauma [2]. US: ultrasound. 1. Abnormal initial US (free fluid or obvious organ damage) 2. Significant hematuria 3. Pelvic fractures 4. 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 a known intraabdominal visceral injury 7. (All polytraumatized patients)a 8. (Every blunt abdominal trauma, thus avoiding unnecessary admission)a
a

still under discussion

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 examination [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 uncooperative 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 the diagnostic procedures of choice in determining intraabdominal 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 adjacent to the emergency resuscitation room, patients still have to be transported to a distant radiologic department. 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 can be brought from the emergency department directly to the operating room. The imaging of the currently available 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.

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Table 4. Advantages of ultrasound (US) over diagnostic peritoneal laUltrasound gave (DPL) and computed tomography (CT) scanning. For more than 30 years, there has been interest in the use of US for evaluating patients with blunt abdominal 1. Bedside capability (resuscitation can continue while sonography is done) trauma [2, 62]. With improved technology, cost-effec2. No contrast agents tiveness and extensive clinical experience, US has 3. No contraindications, except an urgent necessity for laparotomy (sigemerged as the screening test of choice for blunt nificant obesity, widespread subcutaneous emphysema and excessive abdominal trauma in most centers [13, 48, 62]. bowel gas are relative contraindications, as the images are compromised) US has indeed many advantages over DPL and CT 4. No ionizing radiation scanning as stated in Table 4. 5. In addition to the peritoneal cavity, the thorax, pericardium, and Since it involves no hazard from radiation or conretroperitoneum can be examined trast media, the procedure is particularly appealing for 6. Noninvasive pediatric trauma and pregnant women. Furthermore, 7. More cost-effective US can be done serially to reassess the patient [41]. 8. Rapid assessment of abdominal status US has gained its immense popularity because most 9. Suitable for unstable patients to guide the resuscitation team toward or away from laparotomy authors agree that the single, most important criterion 10. No urinary or gastric catheters for laparotomy, the quick and easy demonstration of a 11. Repeatable 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 and were usually due to patient factors (i.e., obesity, large hemoperitoneum. The literature describes a specisubcutaneous emphysema). In indeterminate US, ficity, sensitivity and accuracy for free fluid ranging Boulanger et al. recommend CT scanning for further from 98% to 100%, 81% to 92% and 96% to 99%, diagnosis in stable patients, and in unstable patients the respectively [41, 46, 48, 62, 6470] (Table 5). use of DPL [68]. However, if an intraabdominal injury does not US should be performed in a standardized manner, result in hemoperitoneum or visible organ injury, i.e., as to evaluate the entire abdomen without unnecessary hollow visceral perforation, it may be missed on an inidetailed organ examination, in the literature described tial scan. Therefore, some authors stated repetitive US as FAST (focused assessment with sonography for in case of negative results on initial examination [12]. A trauma). With the patient in the horizontal supine posistudy by Richards et al [60] showed a sensitivity of US in tion, the retrovesical space (pouch of Douglas), the subdetecting blunt bowel or mesenteric injury of 58%. hepatic space (Morisons pouch), and the perisplenic However, in the group of patients with isolated bowel or region are examined for free fluid [3, 68, 73]. The presmesenteric injury, the sensitivity was only 44% on initial ence of fluid at any of these three sites denotes a posiscan. tive FAST. A recent international consensus conference Considering the poorer results for ultrasound localrecommended that also examination of the pericardium ization of injuries, CT will still be required for patients should be included in FAST [62]. being considered for conservative therapy [71]. However, with the improvement of US techniques in organ imaging, several Table 5. Summary of evidence for the use of ultrasound (US) in blunt abdominal trauma. NPV: authors are convinced that in the negative predictive value; PPV: positive predictive value. near future, follow-up imaging of Reference No. of Sensitivity Specificity Accuracy PPV NPV these lesions will be accomplished subjects (%) (%) (%) by repeat sonography, thus eliminating the routine use of serial CT scanBoulanger et al. [64] 206 81 98 96 90 97 McKenney et al. [65] 1,000 88 99 97 94 98 ning [72]. Healey et al. [69] 796 88 98 98 72 99 An additional disadvantage of Arrillaga et al. [46] 104 92 100 99 100 99 US is the fact that it is operatorDolich et al. [48] 2,576 86 98 97 87 98 dependent, and accuracy increases Sirlin et al. [70] 1,047a 89a 98a 97a 61a 99a with experience [41]. Indeterminate a sonograms were reported in 6.7%, in women of reproductive age, where anechoic fluid isolated to the cul-de-sac was considered physiologic

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However, a recent study by Sirlin et al [70] examined the importance of free fluid in women of reproductive 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 does not 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 sensitivity, specificity and accuracy of 89%, 98%, and 97%, respectively, and a negative predictive value of 99% (Table 5). Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is extremely accurate in anatomic definition of structural injury, but today, logistic virtually eliminates its practical application in the evaluation of acute abdominal trauma. Furthermore, 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]. Angiography Angiography of liver and spleen has gained more and more importance over the past few years. An improved visualization of the vascularization made conservative treatment of larger parenchymal lesions possible [2, 3, 72]. During the same procedure, smaller (i.e., subcapsular) bleeding can be treated by embolization. Occasionally, 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 equipment, the time required to complete the study, the need to transport the patient to a distant radiologic department, and the costs. Diagnostic Laparoscopy Together with the current rise in laparoscopic techniques 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 invasiveness of the procedure [3, 47, 74]. There still are limitations 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 pressure, 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 mandatory if CO2 laparoscopy is used for diagnosis and treatment of trauma victims with possible associated head trauma. It seems premature to declare hemodynamic instability an absolute contraindication for the application of laparoscopy, but evidence for this situation is still insufficient, and each individual situation must therefore 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 a positive DPL or CT, thereby reducing the number of unnecessary laparotomies and decreasing hospitalization. An analysis of eleven reports on accuracy of diagnostic laparoscopy published by Leppniemi et al. stated 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 splenectomy. The other three missed injuries were a sealed perforation of the sigmoid colon, a transection of the midbody of the pancreas, and a central retroperitoneal hematoma [47]. A prospective study by Elliott et al. showed a specificity of 100% and a sensitivity of 96% in predicting the need for laparotomy after trauma. However, the sensitivity 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 therapeutic arena. Examples included repair of diaphrag-

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matic laceration, suturing of gastrointestinal perforations, and hemostasis of low-grade hepatic and splenic lacerations [4]. With the improvement of techniques and instrumentations, the appliance of abdominal wall retractor systems 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

Obvious evidence for laparotomy on physical examination

No Hemodynamically stable No Yes

Ultrasound Free peritoneal fluid? Appreciation of pleura, retroperitoneum, and bladder

Ultrasound Free fluid or organ injury?

No Yes Observe

Need for laparotomy, based on US results (i.e., extensive organ injury) Yes Free fluid Laparatomy No free fluid No (or if US is inconclusive) Consider other sources of bleeding Consider DPL for further monitoring certainly if US is inconclusive No Potential for nonsurgical management Yes Observe Yes Indication for immediate extraabdominal surgery

No

CT scan

DPL monitoring or repeated perop. US

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 attention away from the abdomen to other injuries that may be causing hemodynamic instability (i.e., pelvic fractures) [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 consideration should be given to central nervous system, thorax and, of course, the abdomen. However, the timing and appropriateness of the different 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 necessary in case of a negative scan [54, 57]. If the findings of US are abnormal, but do not warrant 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 retroperitoneal 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 viscus injury. For suspected occult bowel and mesenteric injury, 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 indicated if CT scanning is not possible. A potential indication for DPL is the need for urgent therapy for extraabdominal 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 techniques and instrumentations, 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]. References
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Correspondence Address Prof. Dr. Paul Broos Department of Traumatology U.Z. Gasthuisberg Herestraat 49 3000 Leuven Belgium Phone (+32/16) 34-4666, Fax 4614 e-mail: Paul.Broos@uz.kuleuven.ac.be

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