Diagnosing blunt hollow viscus injury: is computed tomography the answer?

Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study

BACKGROUND

Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS).

METHODS

A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance.

RESULTS

The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively.

CONCLUSION

The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury

PURPOSE

Blunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI.

METHODS

We conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI.

RESULTS

One hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67-0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64-0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75-0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55).

CONCLUSION

Radiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist's impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.

Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury

BACKGROUND

Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI.

METHODS

Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention.

RESULTS

1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum (p < 0.0001), active extravasation of contrast (p = 0.0001), hemoperitoneum without solid organ injury (SOI) (p < 0.0001), peritonitis (p < 0.0001), and mesenteric stranding(p < 0.05) were significantly associated with intervention.

CONCLUSION

In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.

CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma

OBJECTIVES

To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma.

METHODS

This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort.

RESULTS

CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI.

CONCLUSIONS

An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination.

KEY POINTS

• A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds

BACKGROUND

Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW.

METHODS

This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed.

RESULTS

Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99).

CONCLUSION

While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level II.

Trauma de recto penetrante: revisión de tema

Introducción. En la actualidad, el trauma de recto continúa siendo una situación clínica compleja y temida por ser potencialmente mortal. Su detección y manejo temprano es la piedra angular para impactar tanto en la mortalidad como en la morbilidad de los pacientes. Hoy en día, aun existe debate sobre la aproximación quirúrgica ideal en el trauma de recto y las decisiones de manejo intraoperatorias se ven enormemente afectadas por la experiencia y preferencias del cirujano. Métodos. Se realizó una búsqueda de la literatura en las bases de datos de PubMed, Clinical Key, Google Scholar y SciELO utilizando las palabras claves descritas y se seleccionaron los artículos mas relevantes publicados en los últimos 20 años; se tuvieron en cuenta los artículos escritos en ingles y español. Discusión. El recto es el órgano menos frecuentemente lesionado en trauma, sin embargo, las implicaciones clínicas que conlleva pasar por alto este tipo de lesiones pueden ser devastadoras para el paciente. Las opciones para el diagnóstico incluyen el tacto rectal, la tomografía computarizada y la rectosigmoidoscopia. El manejo quirúrgico va a depender de la localización, el grado de la lesión y las lesiones asociadas. Conclusión. El conocimiento de la anatomía, el mecanismo de trauma y las lesiones asociadas permitirán al cirujano realizar una aproximación clínico-quirúrgica adecuada que lleve a desenlaces clínicos óptimos de los pacientes que se presentan con trauma de recto.

Application of Computed Tomography in the Identification of Hollow Viscus Injuries in Blunt Trauma Patients

Purpose: Despite advances in diagnostic and imaging technologies, the diagnosis of traumatic hollow viscus injury (HVI) remains a great challenge in clinical practice. This study aimed to determine the accuracy of computed tomography (CT) in the diagnosis of HVI in emergent blunt trauma patients.Methods: The study was conducted on patients with abdominal trauma who were admitted to our center, regional emergency center, Kyung Hee University Medical Center, between January 2008 and December 2018. The clinical data of patients with abdominal trauma who underwent CT and abdominal surgery within 24 hours of hospitalization were analyzed to determine the diagnostic capacity of CT.Results: In total, 156 patients were included in the study. There were 88 cases of blunt trauma. Among these patients, 27 were diagnosed with HVI using CT, and 38 patients were diagnosed with HVI in the operating room. The median injury severity score for these patients was 10.0, the revised trauma score was 7.841, and the trauma injury severity score was 0.96. The sensitivity and specificity of CT in predicting HVI in these patients were 65.8%, and 96.0%, respectively. The positive and negative predictive values were 92.6%, and 78.7%, respectively.Conclusion: In urgent situations, CT findings alone are insufficient for diagnosing HVI. Further research on the HVI diagnostic capacity of CT is required.

Diagnostic Accuracy of Computed Tomography for the Prediction of the Need for Laparotomy for Traumatic Hollow Viscus Injury: Systematic Review and Meta-Analysis

BACKGROUND

Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI.

METHOD

A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models.

RESULTS

Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501-0.809) and 0.969 (95% CI: 0.920-0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011-0.071).

CONCLUSION

In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI.

Significant blunt bowel and mesenteric injury - Comparison of two CT scoring systems in a trauma registry cohort

PURPOSE

This study evaluated and compared two imaging-based scoring systems for the detection of significant blunt bowel and mesenteric injury (sBBMI) by emergency computed tomography (CT).

METHODS AND MATERIALS

We included all consecutive adult polytrauma patients admitted to our emergency department following a road traffic accident from January 2008 to June 2015, provided that intravenously contrast-enhanced whole-body CT examination was performed immediately after hospital admission. Two radiologists, blinded to patients' outcome, reviewed the CT examinations for distinctive direct intestinal or mesenteric vascular injury and indirect signs of abdominal injury. These findings were correlated with the patients' surgical or interventional radiology findings, autopsy, or clinical follow-up (>24 h). Two previously validated imaging-based bowel-injury scoring systems, the CT-based Faget score and the clinically and radiologically based Mc Nutt score (BIPS), were compared by applying each to our trauma cohort. Student t-test, chi-squared, and logistic regression were used in analyses.

RESULTS

Twenty-one of 752 analysed patients (2.8 %) had confirmed sBBMI. Active mesenteric bleeding, mesenteric and free pneumoperitoneum, small haemoperitoneum, non-focal bowel wall thickening, mesenteric/pericolic fat stranding, and anterior abdominal wall injury were significantly correlated with sBBMI, as did the two evaluated scoring systems (p < 0.001). However, multivariate logistic regression revealed the superiority of the Faget score to the McNutt score.

CONCLUSION

The prevalence of sBBMI among polytrauma patients is low. Early diagnosis is necessary to avoid increased mortality. Certain CT features are pathognomic of sBBMI and must not be overlooked. Scoring systems are helpful, especially when they are based on radiological signs.

Damage control in penetrating duodenal trauma: less is better - the sequel

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

Iliac ecchymosis, a valuable sign for hollow viscus injuries in blunt pelvic trauma patients

PURPOSE

Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities.

METHODS

We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted.

RESULTS

In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p < 0.001).

CONCLUSION

IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.

Incidence, outcomes and effect of delayed intervention in patients with hollow viscus injury due to major trauma in the Northern region of New Zealand

BACKGROUND

Patients with hollow viscus injury (HVI) are often a cause for diagnostic uncertainty. The incidence and outcomes of patients suffering hollow viscus injury secondary to major trauma have not been previously described in New Zealand. These metrics are important to guide quality improvement and resource allocation. The aim of our study is to define the incidence, outcomes and effect of delayed intervention on patients admitted to hospital with hollow viscus injury secondary to blunt abdominal trauma in the Northern region of New Zealand.

METHODS

A 4-year multicentre retrospective study was performed in the Northern region of New Zealand between 1 July 2015 and 30 June 2019. A primary cohort of patients with confirmed hollow viscus injury secondary to blunt abdominal injury, who underwent a laparotomy, were assessed. The primary outcome measures were incidence, 30-day mortality and morbidity. Secondary outcomes included the effect of timing of surgical intervention.

RESULTS

The incidence of hollow viscus injury in the region was 2.03 per 100 000. The 30-day mortality rate was 5% and the 30-day morbidity rate was 82%. Immediate surgical intervention was carried out in 36%, early surgical intervention in 56% and delayed surgical intervention in 8%.

CONCLUSION

The incidence of hollow viscus injury is in keeping with similar studies, but with lower mortality and higher morbidity. The rate of immediate or early surgical intervention was high. These findings are important to clinicians managing patients with major trauma and those involved in planning and allocation of resources.

Duodenal Laceration Due to Blunt Trauma Caused by Horse Kick: A Case Report and Literature Review

Patient: Male, 13-year-old

Final Diagnosis: Duodenal laceration

Symptoms: Abdominal pain • diffuse abdominal pain

Medication: —

Clinical Procedure: Laparotomy

Specialty: Surgery

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

Dual-Energy CT: A Paradigm Shift in Acute Traumatic Abdomen

Abdominal trauma, one of the leading causes of death under the age of 45, can be broadly classified into blunt and penetrating trauma, based on the mechanism of injury. Blunt abdominal trauma usually results from motor vehicle collisions, fall from heights, assaults, and sports and is more common than penetrating abdominal trauma, which is usually seen in firearm injuries and stab wounds. In both blunt and penetrating abdominal trauma, an optimized imaging approach is mandatory to exclude life-threatening injuries. Easy availability of the portable ultrasound in the emergency department and trauma bay makes it one of the most commonly used screening imaging modalities in the abdominal trauma, especially to exclude hemoperitoneum. Evaluation of the visceral and vascular injuries in a hemodynamically stable patient, however, warrants intravenous contrast-enhanced multidetector computed tomography scan. Dual-energy computed tomography with its postprocessing applications such as iodine selective imaging and virtual monoenergetic imaging can reliably depict the conspicuity of traumatic solid and hollow visceral and vascular injuries.

Imaging of blunt bowel and mesenteric injuries: Current status

Blunt abdominal trauma often presents a diagnostic challenge. Clinical examination demonstrates low reliability in detecting abdominal injury (16 %) when there is a history of head injury or loss of consciousness. This can prove detrimental, as delays in the diagnosis of traumatic bowel injury of 8 h or less can result in increased morbidity and mortality, as well as prolonged hospitalization. Although hemodynamically unstable patients will require an urgent laparotomy following clinical assessment, MDCT is the modality of choice for comprehensive imaging of blunt abdominal trauma in hemodynamically stable patients. Despite the use of MDCT, blunt injury to the bowel and mesentery, which accounts for up to 5% of injuries in cases of trauma, may be difficult to detect. The use of a constellation of direct and indirect signs on MDCT can help make the diagnosis and guide clinical management. Direct signs on MDCT, such as bowel wall discontinuity, and extraluminal gas may assist in the diagnosis of traumatic bowel injury. However, these signs are not sensitive. Therefore, the astute radiologist may have to rely on indirect signs of injury, such as free fluid, bowel wall thickening, and abnormal bowel wall enhancement to make the diagnosis. This review will focus on MDCT imaging findings of bowel and mesenteric injuries secondary to blunt abdominal trauma.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Traumatic rectal injuries: Is the combination of computed tomography and rigid proctoscopy sufficient?

BACKGROUND

There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries.

METHODS

American Association for the Surgery of Trauma multi-institutional retrospective study (2004-2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive.

RESULTS

One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture.

CONCLUSION

As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis.

LEVEL OF EVIDENCE

Diagnostic, level IV.

The Prognosis of Blunt Bowel and Mesenteric Injury-the Pitfall in the Contemporary Image Survey

Delayed diagnosis and intervention of blunt bowel and mesenteric injury (BBMI) is a hazard because of poor prognosis. Computed tomography (CT) is the standard imaging tool to evaluate blunt abdominal trauma (BAT). However, a high missed diagnosis rate for BMMI was reported. In this study, we would like to evaluate the presentation of CT in BBMI. Moreover, we want to evaluate the impact of deferred surgical intervention of BBMI on final prognosis. We performed a retrospective study from 2013–2017, including patients with BAT and BBMI who underwent surgical intervention. We evaluated clinical characteristics, CT images, and surgical timing, as well as analyzed the prognosis of BBMI. There were 6164 BAT patients and 188 BMI patients included. The most common characteristics of CT were free fluid (71.3%), free air (43.6%), and mesenteric infiltration (23.4%). There were no single characteristics of a CT image that can predict BBMI significantly. However, under close monitoring, we find that deferred intervention did not prolong the hospital and intensive care unit stays and did not worsen the prognosis and mortality.

Isolated free fluid on computed tomography for blunt abdominal trauma

INTRODUCTION

The clinical significance of isolated free fluid on abdominal computed tomography (CT) in patients with blunt abdominal trauma is unclear. This audit reviews our unit's experience with isolated free fluid and attempts to refine our clinical algorithms for the assessment of patients with blunt abdominal trauma.

MATERIALS AND METHODS

All patients who sustained blunt abdominal trauma between December 2012 and December 2017 who were subjected to multidetector CT of the abdomen as part of their initial investigation were included in this study.

RESULTS

During the five-year period under review, a total of 1066 patients underwent abdominal CT following blunt poly trauma. A total of 84 (7.9%) patients died. There were 148 (14%) patients with CT finding of isolated free fluid. Of these, 128 (67%) were selected for non-operative management, which included a period of serial abdominal examinations. In this non-operative group, five patients failed their abdominal observations and underwent laparotomy. Findings in these five cases were negative (1), non-therapeutic (1), splenic injury (1), Pancreatic and splenic injury (1) and bladder injury (1). Thirteen patients (10%) died, none of whom had surgery. The causes of death were exsanguination from a major traumatic lower limb injury (1), multiple organ failure (1), traumatic brain injury (10) and spinal cord injury (1). The remaining 20 patients underwent laparotomy. The indications were failed non-operative management (5), abdominal distension (1) and suspicion of a missed hollow viscus injury (14). In this group there were 11 therapeutic and 6 non-therapeutic surgeries and three negative laparotomies. For the 15 patients selected for operative management, the findings were as follows: hollow viscus injury (3), mesenteric bleeds (2), splenic and pancreatic injury (1), liver and bladder injury (1), splenic and bladder injury (1), non-therapeutic (4), negative (3). The finding of isolated free fluid on CT is 98% sensitive and 96% specific for true isolated free fluid (chi square 331.598; P = 0.000). This finding predicts successful non-operative management with a positive predictive value of 93% and a negative predictive value of 96%.

DISCUSSION

In patients with blunt abdominal trauma, the finding of isolated free fluid on abdominal CT alone is no longer an indication for laparotomy. Other clinical factors must be taken into account when deciding on the need for laparotomy, such as haemodynamic status, clinical abdominal findings and the ability to reliably assess the abdomen. In the absence of a clinical indication for urgent laparotomy, patients with isolated free fluid may be observed.

Ability of specific and nonspecific signs of multidetector computed tomography (MDCT) in the diagnosis of blunt surgically important bowel and mesenteric injuries

PURPOSE

To determine the accuracy of MDCT in the evaluation of blunt surgically relevant bowel and/or mesenteric injuries (BMIs) using single specific CT signs together with specific pairs of nonspecific signs.

METHODS

Fifty-four patients examined with MDCT were divided into two groups: a 'surgical' group of 20 patients-which underwent surgery for blunt BMIs-and a control group of 34 'nonsurgical' trauma patients. Two radiologists with different experience performed a double-blind retrospective evaluation of the images, classifying the patients in the two groups by using only single specific signs; then, the images were reviewed in consensus with a third radiologist and sensitivity and specificity were calculated. Subsequently, the frequency of every single sign and of every possible combination of nonspecific signs in the two groups was registered, to find combinations present only in the surgical group; sensitivity and specificity were calculated by using even those specific combinations.

RESULTS

At the first consensual evaluation, sensitivity and specificity were 75 and 100%, respectively. Two combinations of nonspecific signs (focal wall thickening + extraluminal air; focal wall thickening + seat belt sign) were found only in surgical patients that did not present any single specific sign: Sensitivity calculated adding those two combinations was 95%, without a decrease in specificity.

CONCLUSIONS

MDCT is an accurate technique in the evaluation of blunt surgically relevant BMIs. The single specific CT signs were sufficient for the diagnosis in only 75% of the cases; adding the two specific combinations allowed an increase in sensitivity of 20%.

Outcomes of selective surgery in patients with suspected small bowel injury from blunt trauma

Purpose

The role of initial conservative therapy with selective surgery for patients with suspected blunt bowel injury by radiologic evaluation is less clear. The aim of the study is to assess the outcomes of patients who received initial conservative therapy with selective delayed surgery, compared to emergency surgery.

Methods

During this 8-year study, a total of 77 patients who were hemodynamically stable were enrolled, in which computed tomography verified suspected bowel injury from blunt trauma (mesenteric hematoma, mesenteric fat infiltration, bowel wall thickening, and free fluid without solid organ injury) was managed with either initial conservative therapy with selective delayed surgery (group A; n = 42) or emergency surgery (group B; n = 35). The clinical outcomes including the rate of negative or nontherapeutic exploration and postoperative complications, between the groups were compared.

Results

The enrolled patients had a mean age of 41 years including 51 men and 26 women. No difference in the clinical characteristics was found between the groups. In group A, 18 patients underwent delayed surgery and 24 recovered without surgery. Among patients who underwent surgery, 3 (17%) underwent negative or nontherapeutic explorations. In group B, 13 (37%) underwent negative or nontherapeutic explorations. Postoperative complications occurred in 21 patients and there was no difference between the groups.

Conclusion

Initial conservative therapy with selective delayed surgery did not increased severe postoperative complications and had a low rate of negative or nontherapeutic surgical explorations in hemodynamically stable patients with suspected blunt bowel injury.

Clinical outcomes and effect of delayed intervention in patients with hollow viscus injury due to blunt abdominal trauma: a systematic review

INTRODUCTION

Hollow viscus injury (HVI) due to blunt abdominal trauma remains a diagnostic challenge, often presenting late and results in delayed intervention. Despite several treatment algorithms, there is currently no consensus on how to manage patients with HVI. The aim of this review was to define clinical outcomes and the effect of delayed intervention in patients with HVI due to blunt abdominal trauma. The primary outcome of interest was difference in mortality between groups.

METHODS

Based on the preferred reporting items for systematic reviews and meta-analyses statement, a literature search was performed. Studies comparing clinical outcomes in adult patients with hollow viscus injury due to blunt abdominal trauma undergoing early or delayed laparotomy were included. Two independent reviewers screened the abstracts.

RESULTS

In all, 2288 articles were retrieved. After screening, 11 studies were included. Outcomes in 3812 patients were reported. Overall mortality was 17%. Ten studies reported no difference in mortality between groups. A statistical increase in morbidity was described in five studies, and a trend to increased morbidity was seen in a further two studies. Two studies reported increased mortality in delayed intervention in isolated bowel injury.

CONCLUSIONS

This systematic review summarises the results of studies considering outcomes in patients with HVI due to blunt abdominal trauma who have early vs delayed intervention. Overall mortality was significant at 17%. If all patients with hollow viscus injury are considered, the majority of studies do not show an increase in mortality. As patients with isolated bowel injuries have higher mortality in the studies reviewed, to improve outcomes in this subset further investigation is warranted.

Repeat computed tomography is highly sensitive in determining need for delayed exploration in blunt abdominal trauma

BACKGROUND

Computed tomography (CT) imaging has an established role in the initial evaluation of blunt abdominal trauma. What is less clear is the role of CT in guiding delayed exploration in patients initially managed nonoperatively after blunt trauma. We hypothesized that a repeat CT would accurately identify the need for an exploratory laparotomy in this patient population.

MATERIALS AND METHODS

From 2005 to 2014, we reviewed all blunt abdominal trauma patients at our institution who received an admission CT scan. We identified patients who underwent repeat CT of the abdomen within 72 h for the documented purpose of reevaluating potential intra-abdominal injuries. CT findings were categorized as either having a CT indication for exploration or not, allowing a sensitivity analysis.

RESULTS

Of the 50 patients who met our inclusion criteria, 9 underwent surgical exploration of the abdomen and 41 did not. Admission clinical indicators such as Glasgow Coma Scale, Injury Severity Score, and vitals were similar between the operative and nonoperative groups (P > 0.05). When compared with initial CT scan, repeat scan was found to increase the sensitivity from 67% to 100%, while also improving the specificity to 86%, positive predictive value to 50%, and negative predictive value to 100%.

CONCLUSIONS

Repeat CT scan of the abdomen may be useful in evaluating blunt trauma patients initially managed nonoperatively. The second CT scan increases the sensitivity of CT evaluation to 100% while also improving the specificity, positive predictive value, and negative predictive value.

Accuracy of clinical, laboratory, and computed tomography findings for identifying hollow viscus injury in blunt trauma patients with unexplained intraperitoneal free fluid without solid organ injury

BACKGROUND

We sought to define the accuracy of findings for detecting hollow viscus injury (HVI) in patients with blunt abdominal trauma (BAT) and unexplained intra-peritoneal free fluid without solid organ injury (UIPFFWSOI).

METHODS

We screened all consecutive hemodynamically stable patients presenting to a quaternary-care trauma-centre who had an abdominal computed tomography (CT) scan for BAT and UIPFFWSOI (January 2007-December 2014).

RESULTS

Of 3796 patients identified during the study period, 39 presented with UIPFFWSOI. Fifteen underwent therapeutic laparotomy. Seatbelt sign (+LR approaches infinity), diffuse peritonitis (+LR approaches infinity), number of CT cuts with fluid (c-statistic = 0.65), and a lower arterial pH at presentation (c-statistic = 0.62) were most predictive of HVI. Patients operated on within 24 h had shorter stays than those operated on later (median 9 vs. 14 days, p = 0.03).

CONCLUSIONS

Our findings suggest that clinical examination and measurements of intraperitoneal fluid volume may help identify HVIs in BAT patients.

Isolated free intra-abdominal fluid on CT in blunt trauma: The continued diagnostic dilemma

PURPOSE

The clinical significance of isolated free fluid (FF) without solid organ injury on computed to- mography (CT) continues to pose significant dilemma in the management of patients with blunt abdominal trauma (BAT).

METHODS

We reviewed the incidence of FF and the clinical outcome amongst patients with blunt abdominal trauma in a metropolitan trauma service in South Africa. We performed a retrospective study of 121 consecutive CT scans over a period of 12 months to determine the incidence of isolated FF and the clinical outcome of patients managed in a large metropolitan trauma service.

RESULTS

Of the 121 CTs, FF was identified in 36 patients (30%). Seven patients (6%) had isolated FF. Of the 29 patients who had free fluid and associated organ injuries, 33 organ injuries were identified. 86% (25/ 29) of all 29 patients had a single organ injury and 14% had multiple organ injuries. There were 26 solid organ injuries and 7 hollow organ injuries. The 33 organs injured were: spleen, 12; liver, 8; kidney, 5; pancreas, 2; small bowel, 4; duodenum, 1. Six (21%) patients required operative management for small bowel perforations in 4 cases and pancreatic tail injury in 2 cases. All 7 patients with isolated FF were initially observed, and 3 (43%) were eventually subjected to operative intervention. They were found to have an intra-peritoneal bladder rupture in 1 case, a non-expanding zone 3 haematoma in 1 case, and a negative laparotomy in 1 case. Four (57%) patients were successfully managed without surgical interventions.

CONCLUSIONS

Isolated FF is uncommon and the clinical significance remains unclear. Provided that reli- able serial physical examination can be performed by experienced surgeons, an initial non-operative approach should be considered.

Are We Missing Traumatic Bowel and Mesenteric Injuries?

Purpose

Traumatic bowel and mesenteric injury (TBMI), although an uncommon entity, can be lethal if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (MDCT) for the detection of TBMI in patients at our level 1 trauma centre.

Methods

We used our hospital's trauma registry to identify patients with a diagnosis of TBMI from January 1, 2006, to June 30, 2013. Only patients who had a 64-slice MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in the study cohort. Using the surgical findings as the gold standard, the accuracy of prospective radiology reports was analyzed.

Results

Of the 4781 trauma patients who presented to our institution, 44 (0.92%) had surgically proven TBMI. Twenty-two of 44 were excluded as they did not have MDCT before surgery. The study cohort consisted of 14 males and 8 females with a median age of 41.5 years and a median injury severity score of 27. In total 17 of 22 had blunt trauma and 5 of 22 had penetrating injury. A correct preoperative imaging diagnosis of TBMI was made in 14 of 22 of patients. The overall sensitivity of the radiology reports was 63.6% (95% confidence interval [CI]: 41%-82%), specificity was 79.6% (95% CI: 67%-89%), PPV was 53.9% (95% CI: 33%-73%), and the NPV was 85.5% (95% CI: 73%-94%). Accuracy was calculated at 75.3%. However, only 59% (10 of 17) of patients with blunt injury had a correct preoperative diagnosis. Review of the findings demonstrated that majority of patients with missed blunt TBMI (5 of 7) demonstrated only indirect signs of injury.

Conclusion

The detection of TBMI in trauma patients on 64-slice MDCT can be improved, especially in patients presenting with blunt injury. Missed cases in this population occurred because the possibility of TBMI was not considered despite the presence of indirect imaging signs. The prospective diagnosis of TBMI remains challenging despite advances in CT technology and widespread use of 64-slice MDCT.

Contemporary characteristics of blunt abdominal trauma in a regional series from the UK

INTRODUCTION Blunt abdominal trauma (BAT) is a common injury in recent trauma series. The characteristics of patients with BAT have changed following the reconfiguration of UK trauma services. The aim of this study was to build a new profile for BAT patients undergoing immediate or delayed laparotomy. METHODS All 5,401 consecutive adults presenting with major trauma between April 2012 and April 2014 in the 3 major trauma centres in the West Midlands were analysed to identify all patients with BAT. A total of 2,793 patients with a mechanism of injury or symptomatology consistent with BAT were identified (52%). Outcomes were analysed using local electronic clinical results systems and notes. RESULTS Of the 2,793 patients, 179 (6.4%) had a mesenteric or hollow viscus injury, 168 (6.0%) had a hepatobiliary injury, 149 (5.4%) had a splenic injury and 46 (1.6%) had a vascular injury. Overall, 103 patients (3.7%) underwent an early (<12 hours) laparotomy while 30 (1.1%) underwent a delayed (>12 hours) laparotomy. Twenty (66.7%) of those undergoing a delayed laparotomy had a hollow viscus injury. In total, 170 deaths occurred among the BAT patients (6.1%). In the early laparotomy group, 53 patients died (51.5%) whereas in the delayed laparotomy group, 6 patients died (20.0%). CONCLUSIONS This series has attempted to provide the characteristics of patients with BAT in a large contemporary UK cohort. BAT was found to be a common type of injury. Early and delayed laparotomy occurred in 3.7% and 1.1% of these patients respectively, mostly because of hollow viscus injury in both cases. Outcomes were comparable with those in the international literature from regions with mature trauma services.

Mesenteric Hematoma: Is there a Role for Selective Management?

Mesenteric hematomas may present as a radiologic finding after blunt abdominal trauma that may be associated with surgically significant mesenteric and/or bowel injury. The question of whether to operate or not to operate on patients with mesenteric hematoma remains a topic of debate, especially with the improved imaging technology. This study sought to identify clinical and radiological characteristics for patient selection for operative management (OM) of mesenteric hematoma. A retrospective review of 33 adults with blunt abdominal trauma and mesenteric hematoma on CT scan (2009–2012) was performed. Patients with other intra-abdominal injuries, penetrating trauma, isolated gastric hematoma, contrast extravasation, extraluminal air, and Glasgow Coma Scale < 14 were excluded. Patients requiring surgical treatment within 24 hours of admission were compared with those who did not using chi-squared test, Fisher's exact test, and t test. Parameters included age, gender, race, Glasgow Coma Scale, vital signs, pain, tenderness, ecchymosis, Injury Severity Score, length of stay, and inhospital mortality. Logistic regression was used to determine positive associations with OM. Of the 33 patients, 19 underwent OM and 14 did not. Both groups were similar at baseline. Regression analysis revealed association for pain [odds ratio (OR) = 9.6, confidence interval (CI) = 1.8–49.9, P < 0.01], tenderness (OR = 32, CI = 4.6–222.2, P < 0.01), and free fluid (OR = 10.3, CI = 1.8–60, P < 0.01) with need for operative intervention. Nonoperative management patients had 100 per cent success rate. Of the OM patients, 100 per cent underwent therapeutic laparotomies. Findings of mesenteric hematoma on CT scan in examinable patients with no abdominal pain, tenderness, or free fluid predict successful nonoperative management.

Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries in Patients with Blunt Chest and Abdominal Trauma

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma.

Bowel and mesenteric injuries from blunt abdominal trauma: a review

The bowel and the mesentery represent the third most frequently involved structures in blunt abdominal trauma after the liver and the spleen. Clinical assessment alone in patients with suspected intestinal and/or mesenteric injury from blunt abdominal trauma is associated with unacceptable diagnostic delays. Multi-detector computed tomography, thanks to its high spatial, time and contrast resolutions, allows a prompt identification and proper classification of such conditions. The radiologist, in fact, is asked not only to identify the signs of trauma but also to provide an indication of their clinical significance, suggesting the chance of conservative treatment in the cases of mild and moderate, non-complicated or self-limiting injuries and focusing on life-threatening conditions which may benefit from immediate surgical or interventional procedures. Specific and non-specific CT signs of bowel and mesenteric injuries from blunt abdominal trauma are reviewed in this paper.

Is computed tomography necessary to determine liver injury in pediatric trauma patients with negative ultrasonography?

PURPOSE

Abdominal trauma is the third most common cause of all trauma-related deaths in children. Liver injury is the second most common, but the most fatal injury associated with abdomen trauma. Because the liver enzymes have high sensitivity and specificity, the use of tomography has been discussed for accurate diagnosis of liver injury.

METHODS

Our study was based on retrospective analyses of hemodynamically stabil patients under the age of 18 who were admitted to the emergency department with blunt abdominal trauma.

RESULTS

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were significantly higher as a result of liver injury. In the patients whose AST and ALT levels were lower than 40 IU/L, no liver injury was observed in the contrast-enhanced computed tomography (CT). No liver injury was detected in the patients with AST levels lower than 100 IU/L. Liver injury was detected with contrast-enhanced CT in only one patient whose ALT level was lower than 100 IU/L, but ultrasonography initially detected liver injury in this patient.

CONCLUSIONS

According to our findings, abdominal CT may not be necessary to detect liver injury if the patient has ALT and AST levels below 100 IU/L with a negative abdominal USG at admission and during follow-up.