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Scandinavian Journal of Surgery 91: 5257, 2002 A. K. Malhotra, R. R. Ivatury, R. Latifi



A. K. Malhotra, R. R. Ivatury, R. Latifi

Department of Surgery, Medical College of Virginia, Richmond, VA, U.S.A.
Key words: Abdominal trauma; blunt trauma; diagnostic peritoneal lavage; trauma ultrasound;
computerized tomography; laparotomy indications

Blunt trauma accounts for 8090 % of the trauma volemia (hypotension, tachycardia, tachypnea, air
seen in most civilian trauma centers. Significant ab- hunger) and signs of tissue hypoperfusion (oliguria,
dominal trauma is present in 1215 % of such pa- mental obtundation). A large hemoperitoneum will
tients and usually occurs in association with multi- result in a tender, distended abdomen, and hollow
system injury. Although laparotomy is required in viscus injuries will produce peritonitis. However, it
only 3040 % of patients with blunt abdominal trau- is well known that a strong sympathetic response can
ma, the importance of prompt evaluation and oper- mask systemic signs of hypovolemia, and abdomi-
ative therapy is underscored by the observation that nal distension and signs of peritoneal irritation may
the majority of preventable deaths after blunt trau- be absent in the early hours after trauma. Also, in
ma is due to either unrecognized abdominal injury, the polytraumatized patient, blood loss maybe due
or under-appreciation of the severity of abdominal to other injuries. Furthermore, approximately 40 %
injury (1). This review will focus first on the curren- of the patients have a compromised PE due to head
tly available modalities for evaluation of the abdo- or spine injury, or from the influence of alcohol or
men, and then discuss how these modalities may be drugs. In an attempt to overcome these difficulties,
applied to the multiply injured blunt trauma patient. and increase the sensitivity of PE, four-quadrant tap
Finally the indications for laparotomy in general and was suggested as an adjunct to PE. A four-quadrant
related to specific organs will be presented. tap has a 30 % incidence of false negativity, and a
small incidence of complications, and hence is not
significantly better than PE alone.
MODALITIES FOR EVALUATION Currently repeated PE is utilized in neurologic-
ally intact, conscious patients admitted for observat-
The currently available modalities for evaluating the ion following blunt trauma. If the PE changes signific-
abdomen after blunt trauma include 1. physical ex- antly the patients usually undergo more sensitive
amination, 2. diagnostic peritoneal lavage, 3. compu- and specific diagnostic tests.
terized axial tomography, 4. abdominal ultrasonog-
raphy, and 5. diagnostic laparoscopy. DIAGNOSTIC PERITONEAL LAVAGE

PHYSICAL EXAMINATION Diagnostic peritoneal lavage (DPL) was introduced

by Root et al in 1965 as a sensitive and safe method
Traditionally physical examination (PE) has been the of diagnosing significant intra-abdominal injury (2).
most important and sometimes the sole method of The procedure consists of introducing a peritoneal
evaluating the abdomen. A patient with significant dialysis catheter into the abdomen just below the
blood loss will demonstrate systemic signs of hypo- umbilicus (above if a pelvic fracture is present), ei-
ther percutaneously (closed technique), or through a
small incision (open technique), and directing it to-
wards the pelvis. If the initial aspirate reveals 10 ml
Correspondence: of blood, it indicates significant intra-abdominal he-
Ajai K. Malhotra, M.D. morrhage and the procedure is terminated. If no
Department of Surgery
Medical College of Virginia
blood is aspirated, 1 litre of normal saline is infused
P.O. Box 980454 into the abdomen, and the return is examined for
1200 East Broad Street blood (RBC count > 100,000/mm3; WBC count > 500/
Richmond, VA 23298-0454 mm3), bile, bacteria, or bowel contents. If any of these
U.S.A. are present, it indicates significant intra-abdominal
Email: injury.
Blunt abdominal trauma 53

DPL is a highly sensitive technique (accuracy physis pubis with reconstructions every 710 mm. In
98 %), and soon after its introduction became the an effort to save time, many centers have abandoned
gold standard for diagnosing significant intra-ab- non-enhanced scans. Enhancement is done by power
dominal injury. Although invasive, it is very safe injecting 150 cc of iodinated contrast intravenously,
with < 1 % incidence of complications (3). However just before data acquisition. Enteral contrast with
it suffers from the drawbacks of being oversensitive dilute barium (or diatrizoate) may be given, orally
and nonspecific. Only about 30 ml of blood is re- or by nasogastric tube, 30 minutes prior to the study.
quired for microscopic positivity, and hence when Some centers have stopped using enteral contrast as
used as the sole criteria for surgery, there is a 30 it rarely adds any useful information.
40 % incidence of non-therapeutic laparotomy. It is
nonspecific and hence no comment can be made re-
garding the source of intra-abdominal blood. Many ABDOMINAL SONOGRAPHY
patients operated upon for a positive DPL are found Abdominal sonography (US) has been used to eval-
to have minor liver or spleen injuries that could very
uate blunt abdominal trauma in Japan, and Europe
well have been managed non-operatively. Although since the early 1980s (6). In USA it has been used only
DPL is sensitive for hollow viscus injury, if per-
in the last decade. Rapid ultrasound examination of
formed less than four hours after injury, it is some- the abdomen following blunt trauma (FAST- focused
times falsely negative, as sufficient leukosequestra-
abdominal sonogram for trauma) consists of looking
tion may not have happened to make it positive. Ad- for fluid (usually blood) in four defined areas: 1. sub-
ditional disadvantages include its inability to evalu-
hepatic (hepato-renal interface), 2. subsplenic (lieno-
ate the retroperitoneum, a lower sensitivity in pa- renal interface), 3. pericardial, through a subxiphoid
tients with prior abdominal surgery, and being rela-
window, and 4. pelvic, using a full bladder as an
tively contraindicated in pregnant females. acoustic window. However, in an attempt to increase
Due to these drawbacks and development of other
its sensitivity, experienced sonographers will often
sensitive and more specific noninvasive methods look in additional areas such as subphrenic and para-
of diagnosis, the use of DPL has declined considera-
colic. The advantages of US include its low cost, ra-
bly. Currently its main use is in the rapid determi- pidity, repeatability, portability, and non-invasive-
nation of abdomen being the site of hemorrhage in
ness. Unlike CT, where the patient has to be trans-
the unstable polytrauma patient. It is also useful in ported to the CT area, US can be performed in the
diagnosing hollow viscus injury, when the index of
resuscitation room itself. In experienced hands the
suspicion is high but other tests are negative. sensitivity of US for intra-abdominal fluid has been
reported as 8095 % and approaches that of DPL (7).
The drawbacks of US include its low specificity for
COMPUTERIZED AXIAL TOMOGRAPHY identifying organ injury, and operator dependency.
After its introduction in the early 1970s computer- Also in the presence of subcutaneous emphysema,
ized axial tomography (CT) rapidly came to be uti- obesity, and distended bowel, the examination may-
lized for all parts of the body. In the 1980s a number be suboptimal.
of reports attested to its utility in evaluating the ab- Currently US is most often used, instead of DPL,
domen in hemodynamically stable blunt trauma pa- to rapidly identify hemoperitoneum as the cause of
tients (4). Subsequent prospective studies suggested hypovolemia in hemodynamically unstable patients.
that the accuracy of CT in diagnosing abdominal in- In stable neurologically intact patients US can be
jury was comparable to DPL (5). In addition CT of- used to decide which patients will benefit from a
fers the advantages of being non-invasive, able to CT scan. If the US is completely normal, the patient
specify where the intra-abdominal blood is coming is observed, while if the US shows intra-abdominal
from, and, to a limited extent, evaluate the retroperi- fluid, the patient undergoes a CT scan to identify
toneum and other injuries of the spine and pelvis, at the source of fluid. As resolution increases and sur-
the same time. The disadvantages of using CT for di- geons get more comfortable with its use, it is possi-
agnosing intra-abdominal injury include: 1. the need ble that in the future US will supplant CT as the
to give intravenous contrast (0.1 % incidence of re- screening modality of choice after blunt abdominal
actions, less with more expensive non-ionic contrast); trauma.
2. its relatively poor sensitivity for hollow viscus, ret-
roperitoneal, and diaphragmatic injuries; and 3. the DIAGNOSTIC LAPAROSCOPY
need to transport the patient to the radiology suite
and the time and cost of scans. However, the current Diagnostic laparoscopy is increasingly being used
generation volumetric scanners, helical or spiral, after penetrating trauma. However in blunt trauma
have a much higher resolution hence a greater sen- situations, even in experienced hands it is difficult
sitivity for all types of injury, and can complete scans to look at every part of the intraperitoneal gastroin-
much faster. testinal tract. Visualization is further compromised
CT has largely supplanted DPL as the modality of by blood staining the tissue and sticking to the sero-
choice for evaluating blunt trauma to the abdomen sal surface. Secondly, with currently available tech-
in hemodynamically stable patients, and the tech- niques it is not possible to adequately look at the
nique of scanning has become fairly standardized. retroperitoneum and rule out injury. Lastly, although
Scans are performed from the lower chest to the sym- it is possible to diagnose liver or spleen injuries, and
54 A. K. Malhotra, R. R. Ivatury, R. Latifi

Fig. 1. Algorithm for abdominal evaluation following blunt trauma.

even treat minor injuries, it is difficult to determine HEMODYNAMICALLY UNSTABLE PATIENT

injury grade, which is important for treatment plan-
ning. Another theoretical concern is that the pneu- The diagnostic priority in the unstable blunt trau-
moperitoneum necessary for good visualization may ma patient is to rapidly determine the source of he-
cause air embolism by introducing air into the vas- morrhage while resuscitative measures are being
culature through injured vessels. For these reasons carried out. In rare instances a rapidly distending
as well as the the cost laparoscopy is not often uti- abdomen will suggest abdominal hemorrhage. In
lized after blunt trauma. With developments in op- the absence of this uncommon finding, adjunctive
tics and instrumentation (smaller scopes), and fur- techniques are necessary to rapidly diagnose or rule
ther evolution of the technique (gasless laparoscopy) out major intra-abdominal hemorrhage. Since such
it may play a role in the future. patients cannot be safely transported to the radiol-
ogy department, the diagnostic modalities are some-
what limited. The two modalities commonly used
DPL can be rapidly performed in the resuscitation
In a patient with blunt polytrauma, prior to evaluat- area. Since the objective is to diagnose significant in-
ing the abdomen specifically, it is presumed that the tra-abdominal hemorrhage, and not necessarily the
patient has a patent airway, is ventilating and oxy- specific organ injured, DPL is ideally suited for this
genating, has adequate vascular access (usually two situation. For the same reason, positivity in such sit-
large bore peripheral intravenous lines) and any ob- uations is defined as aspiration of gross blood
vious external sources of bleeding have been control- (> 10 ml), and not on microscopic cell counts. A spe-
led. History, including details of the traumatic inci- cial scenario is the patient with pelvic fracture. DPL
dent, is important in determining how intensive an can be falsely positive because of the fracture he-
evaluation is necessary, and suspecting specific inju- matoma extending upwards. In such patients plac-
ries. The clinical pathway used to evaluate the abdo- ing the DPL catheter through a supraumbilical site
men depends on the hemodynamic stability of the as opposed to the usual infraumbilical site reduces
patient. the incidence of false positivity.
Blunt abdominal trauma 55

The other modality that may be used in the trau- authors of this study however caution that such high
ma room to rapidly diagnose significant intra-ab- accuracy can only be achieved if helical (or spiral)
dominal hemorrhage is US. In trained hands sensi- technology is utilized.
tivity of US for significant intra-abdominal blood ap- In summary, all patients with significant blunt
proaches that of DPL, and US offers the added ad- trauma that are hemodynamically stable need to
vantage of non-invasiveness, and repeatability. As have their abdomen evaluated for injury. Most cent-
surgeons grow more comfortable in using and inter- ers, including the authors, use contrast enhanced hel-
preting US, it will likely replace DPL in these situa- ical CT for this purpose. CT can identify patients that
tions. require operative intervention, and triage patients to
observations in either a regular hospital bed or in the
HEMODYNAMICALLY STABLE PATIENT intensive care unit, or to discharge from the trauma
room. An alternative approach may be to subject all
There continues to be controversy regarding the def- patients to US. If the US does not show any fluid,
inition of hemodynamic stability after trauma. All the patient is admitted for observation, and if the US
commonly used measures of circulatory adequacy shows abdominal fluid, suggesting significant ab-
(heart rate, blood pressure, base excess, serum lac- dominal injury, the patient undergoes CT for diag-
tate, urine output) suffer from limitations. For prac- nosing the source of fluid, and managing accord-
tical purposes a blunt trauma patient may be consid- ingly.
ered hemodynamically stable if after up to two lit-
ers of crystalloid infusion the patient is maintaining
a systolic blood pressure > 90 mmHg (> 100 mmHg INDICATIONS FOR LAPAROTOMY
for older patients), does not have a base deficit, (or
is normalizing the base deficit), and is making > 50 ml AT INITIAL PRESENTATION
of urine every hour. The evaluation of such patients
1. Hemodynamic instability with evidence of intra-
has two aims. First is to rapidly identify patients who
abdominal bleeding (grossly positive DPL or pos-
will need operative therapy, and second is to triage
itive FAST)
patients to optimum level of care observation in the
2. Peritoneal signs
ICU, observation in a regular hospital bed, and dis-
3. Chest radiograph showing evidence of diaphrag-
charge without admission.
matic tear
PE is the simplest form of evaluation. However it
is suitable only for neurologically intact mentally
alert patients. Also it entails admitting virtually all AFTER DIAGNOSTIC TESTING
patients for repeated examination, and takes up sig-
nificant time and personnel resources to be effective. Diagnostic tests showing:
Even if all these limitations are acceptable, the length 1. active extravasation from a major abdominal ves-
of time patients should be observed is not clear. Al- sel or a contained hematoma adjacent to a major
though the large majority of patients with significant vessel suggesting injury
injury requiring intervention will be diagnosed with- 2. solid organ injury with active extravasation
in 24 hours of observation, a small number will be 3. pancreatic injury
missed, as they may not demonstrate signs of injury 4. hollow viscus injury
in this timeframe (e.g. a patient with a small colonic 5. intraperitoneal bladder rupture
perforation with minimal soilage, or a mesenteric in-
jury with devascularized bowel). DPL is highly sen- DURING HOSPITAL OBSERVATION
sitive for significant abdominal injury, but is inva-
sive, nonspecific, and results in an unacceptably high 1. Patient with solid organ injury being managed
incidence of non-therapeutic laparotomy. US may be non-operatively developing hemodynamic insta-
a good screening modality, as it is noninvasive and bility or requiring > 2 units of packed cell transfu-
its sensitivity approaches that of DPL. However US sion related to the solid organ injury
can miss a small amount of fluid in the peritoneum, 2. Development of peritonitis
which may be the only finding in a patient with sig- 3. Persistent urinary leakage or persistent hematuria
nificant bowel injury. Further all three modalities do from a fragmented kidney
not address the second aim of evaluation triage. Of 4. Patient with negative initial evaluation but not
the currently available modalities the one that comes improving or showing clinical deterioration, with
closest to meeting the two aims of evaluation in a sta- no other explanation
ble patient is CT. A contrast enhanced CT can not
only diagnose specific injuries, it can grade solid or- SPECIFIC ORGAN INJURIES
gan injury thus facilitating the decision making proc-
ess regarding the optimum level of care for a given SOLID ORGANS LIVER AND SPLEEN
patient. In a large prospective multi-institutional
study of over 2000 patients it was shown that patients Liver and spleen are the two most common organs
evaluated by CT after blunt trauma could safely be that are injured following blunt abdominal trauma.
discharged from the emergency department if the CT Non-operative management of these injuries has
was completely normal and the patients did not have evolved over the past two decades. Currently all he-
any other indication for hospital admission (8). The modynamically stable patients with liver and/or
56 A. K. Malhotra, R. R. Ivatury, R. Latifi

spleen injuries detected by CT are managed non-op- DIAPHRAGM

eratively (9, 10). Patients who on CT scan demon-
strate active extravasation of intravenous contrast All diaphragm injuries should be operatively re-
and yet are stable may either be managed by imme- paired. If repair is not done in the acute setting these
diate angiography with selective embolization of the patients may present years later with chronic dia-
bleeding vessel, or undergo urgent laparotomy. The phragmatic hernias and respiratory compromise, or
decision to go for surgery or control by interventional strangulation. Larger ruptures are easily detected by
radiology is usually based on the locally available chest radiography. Smaller injuries can be missed.
expertise and resources. In the absence of active con- None of the available diagnostic modalities are re-
trast extravasation, patients with these injuries are liable in detecting such injuries. The newer genera-
managed by observation in the intensive care unit. tion helical scanners may show some subtle signs
Any such patient developing hemodynamic instabil- such as thickening of the hemidiaphragm. In the
ity or requiring > 2 units of packed cell transfusion absence of a reliable diagnostic test, the surgeon has
due to the solid organ injury should undergo urgent to maintain a high index of suspicion based on the
laparotomy. history more common with a mechanism involv-
ing a crushing force to the upper abdomen or chest.
If the index of suspicion is high, laparoscopy may
PANCREAS be utilized to not only diagnose the injury, but re-
Pancreatic injuries are often detected at surgery as pair it also. In rare cases exploratory laparotomy
these patients usually have associated injuries that may be necessary to establish the diagnosis and re-
require laparotomy. Isolated injuries of the pancreas pair the injury.
however can be difficult to detect. Enzyme elevation
is fairly sensitive, but nonspecific. CT done in the ear- URINARY TRACT
ly post trauma period may fail to show injury. If the
initial CT does not show injury and the index of sus- Majority of renal injuries following blunt trauma
picion, based on mechanism or persistent enzyme el- does not require laparotomy. Laparotomy and repair
evation, is high, the CT can be repeated. In such sit- is indicated if there is urinary extravasation that is
uations the technique should be modified to get thin persistent over 4872 hours. In most patients present-
sections through the pancreas and to time the scan ing with gross hematuria, the hematuria usually re-
so that data acquisition is done when the intravenous solves. In cases where the hematuria does not re-
contrast is within the organ. Patients with CT show- solve, and the imaging studies suggest renal frag-
ing injury need laparotomy for drainage with or mentation, laparotomy may be required to remove
without resection. Alternatively MR pancreatogra- whole or part of the kidney. The warm ischemia time
phy, where available, offers a noninvasive way to for the kidney is four to six hours, and hence at-
evaluate the pancreatic duct. Major ductal injury is tempts at revascularization after traumatic avulsion
an indication for laparotomy, while if the injury does or thrombosis of the renal artery are usually futile.
not involve the major ducts, the patient maybe man- In rare instances when the diagnosis has been made
aged non-operatively. early, the patient is hemodynamically stable, and it
is important to preserve renal parenchyma (solitary
kidney, borderline renal function), laparotomy for
HOLLOW VISCUS revascularization may be justified.
Blunt ureteric injury is rare and usually occurs
Hollow viscus injury is the third most common in-
with other major injuries that require laparotomy.
jury seen after blunt abdominal trauma. Delay in op-
Intraperitoneal rupture of the bladder is usually seen
erative therapy following such injuries can lead to
in association with a pelvic fracture or when there
significant morbidity and mortality. Patients with
has been a blow to the lower abdomen with a dis-
peritoneal signs, either at initial presentation or dur-
tended bladder. In conscious patients peritoneal
ing observation in the hospital, should undergo
signs are present. CT scan usually shows free intra-
laparotomy without delay. Although CT has tradi-
peritoneal fluid. Injury may be confirmed by retro-
tionally been considered poor in the diagnosis of
grade or CT cystography. Once the diagnosis is
these injuries, the current helical scanners have in-
made, laparotomy is indicated to repair the bladder.
creased the accuracy considerably. Individual find-
ings of bowel or mesenteric injury unexplained in-
traperitoneal free fluid; pneumoperitoneum; bowel REPRODUCTIVE ORGANS
wall thickening; mesenteric fat streaking; mesenteric
hematoma; extravasation of luminal or vascular con- Injuries to the intra-abdominal reproductive organs
trast are nonspecific, but they can raise suspicion are rarely isolated in the non-gravid patient, and are
of hollow viscus injury, and prompt further tests or found during laparotomy for other reasons.
laparotomy. In a recent report the number of CT find-
ings was found to directly correlate with presence of ABDOMINAL VESSELS
injury (11). In that report the authors suggest doing
a DPL for a single CT finding, and proceeding with Injuries to the major abdominal vessels usually cause
laparotomy if more than one finding is present. hemodynamic instability, and are found at laparot-
omy. In some instances the bleeding may have
stopped, and a pseudoaneurysm is detected on CT
Blunt abdominal trauma 57

scan. If the pseudoaneurysm involves any major ves- 04. Federle MP, Crass RA, Jeffrey RB, Trunkey DD: Computed
sel, immediate laparotomy is indicated to repair the tomography in blunt abdominal trauma: Arch Surg 1982;117:
vessel and prevent exsanguinating hemorrhage. 05. Meyer DM, Thal ER, Weigelt JA: Evaluation of computed to-
mography and diagnostic peritoneal lavage in blunt abdomi-
nal trauma: J Trauma 1989;29:11681172
CONCLUSIONS 06. Aufschnaiter M, Cofler H: Sonographic acute diagnosis in
polytrauma: Aktuel Traumatol 1983;13:5557
07. McKenney MG, Martin L, Lentz K, Lopez C, Sleeman D,
Blunt trauma accounts for large majority of civilian Aristide G, Kirton O, Nunez D, Najjar R, Namias N, Sosa J:
trauma. Prompt evaluation of the abdomen is neces- 1,000 consecutive ultrasounds for blunt abdominal trauma: J
sary to minimize preventable morbidity and mortal- Trauma 1996;40:607612
ity. Unstable patients with evidence of intra-abdom- 08. Livingston DH, Lavery RF, Passannante MR, Skurnick JH, Fa-
bian TC, Fry DE, Malangoni MA: Admission or observation
inal hemorrhage (by US or grossly positive DPL) is not necessary after a negative abdominal computed tomo-
should undergo laparotomy immediately. Of the graphic scan in patients with suspected blunt abdominal trau-
multiple modalities available for evaluating stable ma: Results of a prospective, multi-institutional trial: J Trau-
patients, contrast enhanced CT provides the most ma 1998;44:280282
09. Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG,
useful information for deciding which patient needs Clancy KD, Croce M, Enderson BL, Morris JA, Shatz D, Me-
operative therapy, observation in the intensive care redith JW, Ochoa JB, Fakhry SM, Cushman JG, Minei JP, Mc-
unit or hospital, or can be safely discharged from the Carthy M, Luchette FA, Townsend R, Tinkoff G, Block EF,
emergency department. Ross S, Frykberg ER, Bell RM, Davis F, Weireter L,
Shapiro MB: Blunt splenic injury in adults: multi-institutional
study of the EAST: J Trauma 2000;49:177189
10. Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Mi-
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