Multidetector CT evaluation of abdominal trauma

CT findings of inferior vena cava trauma according to the level of injury: a retrospective analysis of 19 cases in a single trauma centre

AIM

To analyse the clinicoradiological characteristics of traumatic inferior vena cava (IVC) injury level on preoperative computed tomography (CT).

MATERIALS AND METHODS

This retrospective study evaluated patients from a single trauma centre treated for traumatic IVC injury between January 2014 and January 2021. Data on demographics, mechanism of injury, Injury Severity Score, radiological findings on CT and angiography, IVC injury level in surgical findings, complications, and clinical outcomes were collected.

RESULTS

During the 8-year study period, 36 patients presented with traumatic IVC injury: 19 underwent preoperative CT with 17 (89%) blunt and two (11%) penetrating injuries. The most common primary CT sign was contour abnormality (53%, n=10), followed by intraluminal flap and active extravasation (21%, n=4). Among the secondary signs, hepatic laceration (53%, n=10) and retroperitoneal haemorrhage (53%, n=10) were the most common. Frequencies of primary and secondary signs were higher in the infrarenal and suprarenal than in the retrohepatic vena cava injuries. Diagnostic capability of preoperative CT for IVC injury differed according to the IVC level. The detection rate was the highest for an infrarenal vena cava injury at 100% (n=4), followed by that for a suprarenal, suprahepatic, and retrohepatic vena cava injuries at 75% (n=3), 43% (n=3), and 25% (n=1), respectively.

CONCLUSION

CT findings of traumatic IVC injuries may vary depending on the mechanism and anatomical site of injury. Familiarity with IVC injury imaging features may help in diagnosis and surgical treatment planning.

Factors associated with enteral nutrition tolerance after trauma laparotomy of the small bowel and mesenteric injuries by blunt trauma

BACKGROUND

In patients with blunt injury due to abdominal trauma, the common cause for laparotomy is damage to the small bowel and mesentery. Recently, postoperative early enteral nutrition (EEN) has been recommended for abdominal surgery. However, EEN in patients with blunt bowel and/or mesenteric injury (BBMI) has not been established. Therefore, this study aimed to identify the factors that affect early postoperative small bowel obstruction (EPSBO) and the date of tolerance to solid food and defecation (SF + D) after surgery in patients with BBMI.

METHODS

We retrospectively reviewed patients who underwent laparotomy for BBMI at a single regional trauma center between January 2013 and July 2021. A total of 257 patients were included to analyze the factors associated with enteral nutrition tolerance in patients with EPSBO and the postoperative day of tolerance to SF + D.

RESULTS

The incidence of EPSBO in patients with BBMI was affected by male sex, small bowel organ injury scale (OIS) score, mesentery OIS score, amount of crystalloid, blood transfusion, and postoperative drain removal date. The higher the mesentery OIS score, the higher was the EPSBO incidence, whereas the small bowel OIS did not increase the incidence of EPSBO. The amount of crystalloid infused within 24 h; the amount of packed red blood cells, fresh frozen plasma, and platelet concentrate transfused; the time of drain removal; Injury Severity Score; and extremity abbreviated injury scale (AIS) score were correlated with the day of tolerance to SF + D. Multivariate analysis between the EPSBO and non-EPSBO groups identified mesentery and small bowel OIS scores as the factors related to EPSBO.

CONCLUSION

Mesenteric injury has a greater impact on EPSBO than small bowel injury. Further research is needed to determine whether the mesentery OIS score should be considered during EEN in patients with BBMI. The amount of crystalloid infused and transfused blood components within 24 h, time of drain removal, injury severity score, and extremity AIS score are related to the postoperative day on which patients can tolerate SF + D.

Single Center Retrospective Review of Post-laparotomy CT Abdomen and Pelvis Findings and Trends

Purpose

To identify common findings visualized on CT following damage control laparotomy, including post-surgical changes and additional injuries, and to determine change in frequency of post-laparotomy CT at our institution over time.

Methods

Single institution, IRB-Exempt, retrospective review of the University of Kentucky trauma registry from 1/2006 to 2/2019 for all trauma patients undergoing exploratory laparotomy initially and subsequently undergoing CT of the abdomen and pelvis within 24 hours. Operative findings from surgical operation notes and findings reported on post-laparotomy CT were recorded, including vascular and solid organ injuries, operative changes, free intraperitoneal fluid/air, and retroperitoneal findings. Next steps in management were also recorded.

Results

In total 1,047 patients underwent exploratory laparotomy initially at our institution between 1/2006-2/2019. Of those, only 96 had a diagnostic CT of the abdomen and pelvis within 24 h after initial surgery, first occurring in 2010. Among these 96, there were 71 blunt and 25 penetrating injuries. Most common injuries recognized during exploratory laparotomy were bowel/mesentery (55), spleen (34), and liver (26). Regarding CT findings, all patients (96/96, 100%) had residual pneumoperitoneum, 84/96 (87.5%) had residual hemoperitoneum, 36/96 (37.5%) noted post-surgical changes or additional injuries to the spleen, 36/96 (37.5%) to the bowel/mesentery, and 32/96 (33.3%) to the liver, and 34/96 (35.4%) were noted to have pelvic fractures. After CT, 31/96 (32.3%) went back to the OR for relook laparotomy and additional surgical intervention and 7/96 (7.3%) went to IR for embolization. Most common procedures during relaparotomy involved the bowel (8) and solid organs (6).

Conclusions

CT examination within 24 h post damage control laparotomy was exceedingly rare at our institution prior to 2012 but has steadily increased. Frequency now averages 20.5% yearly. Damage control laparotomy is an uncommon clinical scenario; however, knowledge of frequent injuries and common post-operative changes will aid in radiologist detection of additional injuries helping shape next step management and provide adequate therapy.

Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses

Duodenal pathology is an infrequent cause of acute abdominal pain for which patients present to the emergency department. Critical pathology on multidetector CT (MDCT) may be overlooked if the radiologist does not carefully evaluate the duodenum as part of the search pattern. Optimal MDCT protocols include intravenous contrast with multiplanar reconstructions (MPRs). A variety of etiologies ranging from infection to malignancy can involve the duodenum, for which interrogation with MPRs is most helpful given the anatomy and complex relationship with surrounding structures. The purpose of this review article is to highlight the importance of CT acquisition with multiplanar reconstructions and review the spectrum of emergent duodenal pathology, with the goal of ensuring accurate and timely diagnosis to best guide patient management.

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%.

Pancreaticobiliary Trauma: A Multimodality Imaging Update

Pancreaticobiliary injury is an uncommon entity which more often occurs in the setting of blunt than penetrating trauma. We present cases of pancreaticobiliary traumatic injuries from our Level 1 trauma center to illustrate an imaging update on the spectrum of injuries and correlation with current grading systems.

Duodenal trauma

Duodenal trauma represents a unique challenge to the surgeon due to its relative rarity, anatomic location, and often the difficulty in diagnosing and managing these injuries. Despite these challenges, significant advances have been made over the previous century, and mortality has fallen to as low as 17%. The CT scan is the primary modality for diagnosis in the blunt trauma patient, and thorough surgical exploration at laparotomy is the mainstay for penetrating injuries. Management is guided by the grade of injury, with low-grade hematomas managed by observation, intermediate grade injuries by primary repair, and high-grade injuries with a damage control surgery approach. While pyloric exclusion remains the most common technique to augment primary repair in intermediate and higher grade injuries, the utility of this procedure has come into question in current literature, and an overall ‘less-is-more’ surgical approach has been advocated in recent publications. Complications following duodenal trauma are common and include fistulae, duodenal obstruction, and infectious complications. However, the overall morbidity and mortality have improved with these injuries. Future investigation is needed to determine the optimal management approach for these challenging patients.

Indirect signs of blunt duodenal injury on computed tomography: Is non-operative management safe?

INTRODUCTION

Clear signs of duodenal injury (DI) such as pneumoperitoneum and/or oral contrast extravasation mandate laparotomy. Management when computed tomography (CT) reveals indirect evidence of DI namely duodenal hematoma or periduodenal fluid is unclear. We evaluated the utility of indirect signs to identify DI and the success of expected management, hypothesizing patients with indirect evidence of DI on CT can be safely managed non-operatively.

METHODS

We retrospectively reviewed patients with a computed tomography (CT) scan with periduodenal hematoma or periduodenal fluid treated between January 2003 and January 2013 at a level 1 Trauma Center. Demographics, injury characteristics, laboratory values, injury severity scores (ISS), and outcome measures were recorded. Patients having immediate laparotomy were compared to those initially managed nonoperatively.

RESULTS

We identified 74 patients with indirect signs of DI, with 35 patients (47%) undergoing immediate operative exploration and 39 (53%) initially managed non-operatively. Lactate (4.5 mg/dL, standard deviation (SD) 2.1 vs 3.1 mg/dL, SD 1.4, p<0.001), ISS (median (IQR) 34 (27-44) vs. 24 (17-34), p=0.002) and abdominal AIS (3 (3-4) vs 2 (2-3), p<0.001) were higher in those with immediate operation. The incidence of DI requiring operative repair was 11% (8 of 74). Six of 35 (17%) explored urgently had a DI requiring repair while 29 of 35 (83%) had no DI or minor injury not requiring surgical therapy. Of those managed non-operatively, 7 of 39 (18%) failed observation but only two (5%) required duodenal repair. There was no significant difference in intensive care unit (ICU) (10.2 days, standard error [SE] 2.1 vs 9.7 days, SE 4.8, p=0.93) or hospital (22.5 days, SE 3.8 vs 23.6 days, SE 8.5, p=0.91) length of stay between those operated on immediately and those that failed non-operative management when adjusted for age, sex, and ISS. There was no mortality in the non-operative group related to an intra-abdominal injury.

CONCLUSION

Observation of patients with indirect sign of DI fails in about 20% of patients, but failure rate due to DI is low at 5%. Conservative management in appropriately selected patients is reasonable with close observation.

[Place of non-operative treatment of abdominal contusions in developing countries]

Le traitement non opératoire des contusions de l'abdomen représente une approche thérapeutique nouvelle des traumatismes fermés de l'abdomen. La disponibilité d'un plateau technique performant constitue classiquement une des principales conditions pour la réussite de cette attitude. Nous essayons d’étudier les différents aspects épidémiologiques, diagnostiques et thérapeutiques de cette affection dans le contexte d'un pays en voie de développement, à travers les résultats d'une série de 106 malades. une série de 106 patients est prise en charge par le traitement non opératoire. La gravité des lésions est appréciée par les données cliniques et paracliniques, ainsi que la morbidité et la mortalité sont analysées. les accidents de la circulation étaient la première cause des contusions abdominales, dans notre contexte. Les lésions hépatiques étaient les plus fréquentes (65% des cas), suivit des lésions spléniques chez 19 patients. La notion de polytraumatisme était très fréquente. La durée moyenne de surveillance était de 9,5 jours. Seize malades étaient transfusés, et le nombre moyen de culots globulaires (CG) était de 3,5 culots par patient. Une laparotomie en urgence était indiquée chez 10 patients (9.4%) devant l'instabilité hémodynamique. Trois malades ont nécessité un traitement chirurgical secondaire. On avait noté un taux de mortalité de 3.7% soit 4 cas. il semble à partir de notre expérience que l'abstention chirurgicale peut constituer, dans des conditions strictes de surveillance, une alternative thérapeutique de référence dans les pays en voie de développement, sûre et justifiée à une chirurgie d'urgence toujours difficile.

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.

Organ laceration grading adherence by radiologists

American Association for the Surgery of Trauma (AAST) abdominopelvic organ laceration grading is used to determine which patients can be managed non-operatively. We assess a change in the use of AAST grading system by radiologists at a single, large, academic institution before and after a one-time departmental intervention and reviewed non-graded reports evaluating if grading could be inferred. After IRB approval, a keyword search for "laceration" identified traumatic abdominopelvic CT reports in a 2-year period before and after the one-time intervention. Reports were reviewed to determine if an organ laceration was seen, if it was graded by AAST criteria, and if grading could be inferred for non-graded reports. T test was performed to assess statistical significance. Before the intervention, 348 reports contained the keyword "laceration," 81 with lacerations, 31 graded (38 %). After the intervention, 302 reports were found, 79 with lacerations, 59 graded (75 %). The increase was statistically significant (p < 0.0001). A decreasing trend in grading was seen over time following the intervention. Two out of 50 (4 %) pre-intervention and four out of 20 (20 %) post-intervention reports gave enough detailed descriptions for the grading to be inferred when it was not explicitly stated. Non-graded reports did not describe laceration parenchymal depth and subcapsular hematoma surface area percentage; however, the presence/absence of active extravasation, omitted in the 20-year-old AAST grading scheme, was described in every report. One-time departmental intervention yielded a significant increase in adherence to AAST laceration grading. Lack of perfect compliance, which diminished over time, suggests a need for further reinforcement.

The Impact of Transient Hepatic Attenuation Differences in the Diagnosis of Pseudoaneurysm and Arteriovenous Fistula on Follow-Up CT Scans after Blunt Liver Trauma

A feared complication to liver trauma is delayed vascular complication, such as pseudoaneurysm and arteriovenous fistula (PS/AF) seen as focal enhancement on contrast-enhanced computed tomography (CT) in the arterial phase. A hyperdense area termed transient hepatic attenuation difference (THAD) representing altered hepatic blood flow can be seen in the arterial phase near the liver lesion. The objective of this study was to describe THAD and PS/AF on follow-up CT after blunt liver trauma, and to evaluate if THAD influenced the evaluation of PS/AF. Three radiology residents retrospectively evaluated scans of 78 patients. The gold standard for PS/AF was an evaluation by an experienced senior radiologist, while THAD was a consensus between the residents. PS/AF was present in 14% and THAD in 54%. THAD was located in the periphery of the lesion with hazy borders and mean HU levels of 100, while PS/AF was located within the lesion with focal enhancement and mean HU levels of 170 (p < 0.05). In evaluation of PS/AF, the likelihood of agreement between the observers and the gold standard was 89% when THAD was present, and 98% when THAD was absent (p = 0.04). THAD is common and can hamper the evaluation of PS/AF.

Iterative reconstruction improves image quality and preserves diagnostic accuracy in the setting of blunt solid organ injuries

This study aims to investigate the effect of iterative reconstruction (IR) on MDCT image quality and radiologists' ability to diagnose and grade blunt solid organ injuries. One hundred (100) patients without and 52 patients with solid organ injuries were scanned on a 64-slice MDCT scanner using reference 300 mAs, 120 kVp, and fixed 75 s delay. Raw data was reconstructed using filtered back projection (FBP) and three levels of iterative reconstruction (Philips iDose levels 2, 4, and 6). Four emergency radiologists, blinded to the reconstruction parameters and original interpretation, independently reviewed each case, assessed image quality, and assigned injury grades. Each reader was then asked to determine if they thought that IR was used and, if so, what level. There was no significant difference in diagnostic accuracy between FBP and the various IR levels or effect on the detection and grading of solid organ injuries (p > 0.8). Images reconstructed using iDose level 2 were judged to have the best overall image quality (p < 0.01). The radiologists had high sensitivity in detecting if IR was used (80 %, 95 % CI 76-84 %). IR performed comparably to FBP with no effect on radiologist ability to accurately detect and grade blunt solid organ injuries.

The role of follow-up ultrasound and clinical parameters after abdominal MDCT in patients with multiple trauma

BACKGROUND

Beside its value during the initial trauma work-up (focused assessment with sonography for trauma), ultrasound (US) is recommended for early follow-up examinations of the abdomen in multiple injured patients. However, multidetector CT (MDCT) has proven to reliably diagnose traumatic lesions of abdominal organs, to depict their extent, and to assess their clinical relevance.

PURPOSE

To evaluate the diagnostic impact of follow-up US studies after MDCT of the abdomen and to identify possible clinical parameters indicating the need of a follow-up US.

MATERIAL AND METHODS

During a 30-month period, patients with suspected multiple trauma were allocated. Patients with admission to the ICU, an initial abdominal MDCT scan, and an US follow-up examination after 6 and 24 h were included. Two patient cohorts were defined: patients with normal abdominal MDCT (group 1), patients with trauma-related pathologic abdominal MDCT (group 2). In all patients, parameters indicating alteration of vital functions or hemorrhage within the first 24 h were obtained by reviewing the medical charts.

RESULTS

Forty-four of 193 patients were included: 24 were categorized in group 1 (mean age, 41.1 years; range, 21-90 years), 20 in group 2 (mean age, 36.6 years; range, 16-71 years). In group 1, US did not provide new information compared to emergency MDCT. In group 2, there were no contradictory 6- and 24-h follow-up US findings. In patients with positive MDCT findings and alterations of clinical parameters, US did not detect progression of a previously diagnosed pathology or any late manifestation of such a lesion. In none of the patients with negative abdominal MDCT and pathological clinical parameters US indicated an abdominal injury.

CONCLUSION

Routine US follow-up does not yield additional information after abdominal trauma. In patients with MDCT-proven organ lesions, follow-up MDCT should be considered if indicated by abnormal clinical and/or laboratory findings.

Predicting hollow viscus injury in blunt abdominal trauma with computed tomography

BACKGROUND

Evaluation of blunt abdominal trauma is controversial. Computed tomography (CT) of the abdomen is commonly used but has limitations, especially in excluding hollow viscus injury in the presence of solid organ injury. To determine whether CT reports alone could be used to direct operative treatment in abdominal trauma, this study was undertaken.

METHODS

The trauma database at Auckland City Hospital was accessed for patients who had abdominal CT and subsequent laparotomy during a five-year period. The CT scans were reevaluated by a consultant radiologist who was blinded to operative findings. The CT findings were correlated with the operative findings.

RESULTS

Between January 2002 and December 2007, 1,250 patients were evaluated for blunt abdominal injury with CT. A subset of 78 patients underwent laparotomy, and this formed the study group. The sensitivity and specificity of CT scan in predicting hollow viscus injury was 55.33 and 92.06 % respectively. The positive and negative predictive values were 61.53 and 89.23 % respectively. Presence of free fluid in CT scan was sensitive in diagnosing hollow viscus injury (90 %). Specific findings for hollow viscus injuries on CT scan were free intraperitoneal air (93 %), retroperitoneal air (100 %), oral contrast extravasation (100 %), bowel wall defect (98 %), patchy bowel enhancement (97 %), and mesenteric abnormality (94 %).

CONCLUSIONS

CT alone cannot be used as a screening tool for hollow viscus injury. The decision to operate in hollow viscus injury has to be based on mechanism of injury and clinical findings together with radiological evidence.

Management of blunt renal injury in a level 1 trauma centre in view of the European guidelines

BACKGROUND

Debate continues about the optimal management strategy for patients with renal injury.

PURPOSE

To report the diagnostics and treatment applied in a level 1 trauma centre and to compare it to the recommendations of the European Association of Urology guidelines concerning blunt renal injury.

METHODS

The management of all patients with blunt renal injury, admitted to the level 1 trauma centre of the Academic Medical Centre, between January 2005 and December 2009 was reviewed retrospectively.

RESULTS

Median age and ISS of the 186 included patients were 40 and 17 years respectively. All but one haemodynamically stable patients with microscopic haematuria received nonoperative management. Sixty percent of the haemodynamically stable patients with gross haematuria underwent CT scanning. Patients with grade 1-4 renal injury received nonoperative management. Additionally, two patients with grade 3-4 renal injury received angiography and embolization (A&E). One patient with grade 5 injury underwent renal exploration and two A&E. Seven of the 8 haemodynamically unstable patients underwent emergency laparotomy and in 2 patients, haemodynamically unstable because of renal injury, A&E was performed as an adjunct to surgical intervention.

CONCLUSIONS

In the present study, violation of the guidelines increased with injury severity. A&E can provide both a useful adjunct to nonoperative management and alternative to surgical intervention in specialised centres with appropriate equipment and expertise, even in patients with high grade renal injury. We advocate an update of the guidelines with a more prominent role of A&E.

Correlation of operative and pathological injury grade with computed tomographic grade in the failed nonoperative management of blunt splenic trauma

BACKGROUND

Computed tomography (CT) is the standard for grading blunt splenic injuries, but the true accuracy, especially for grade IV or V injuries as compared to pathological findings, is unknown.

STUDY DESIGN

A retrospective study from 2005 to 2011 was undertaken.

RESULTS

There were 214 adults admitted with blunt splenic injury and 170 (79%) were managed nonoperatively. The remaining 44 patients (21%) required surgical intervention. There was a significant difference in the Injury Severity Score (ISS) between those who did and those who did not require splenectomy: median 31 (interquartile [IQ] range 11-51) versus 22 (IQ range 9-35, p = 0.0002). Ten patients presented in shock, had a positive ultrasound, and went to surgery. The remaining 34 had CT scans prior to surgery. Twenty-five (73%) had injury grades IV or V. The CT scan correctly graded the injury in 14 (41%) and was incorrect in 20 (59%). The assigned grade by the CT scan underestimated the true injury grade by one grade in six cases (30%), by two or more grades in nine (45%), and the CT images were obscured by blood and deemed "ungradeable" in five (25%). The CT scan was more accurate for grades I and II (100%) than for grades III-V (25-43%). The reasons for inaccuracy were either inability to visualize that the laceration involved the hilar vessels or excessive perisplenic blood which obscured the injury and/or the hilum.

CONCLUSIONS

CT for splenic injury is accurate for grades I and II, but underestimates the true extent of injury for grades III-V. The reasons for the lack of correlation are the inability to determine hilar involvement and excessive perisplenic blood obscuring the injury. Patients with these image characteristics by CT scan should undergo splenectomy earlier if there are any signs of hemodynamic instability.

Multi detector computed tomography in the diagnosis of bowel injury

Bowel Injuries are uncommonly associated with traumatic abdominal injuries. However, they are associated with significant morbidity and mortality and require operative intervention unlike solid organ injuries. Hence, early diagnosis is of paramount importance. Computed tomographic (CT) scan is a well-established and highly accurate imaging modality for the detection of solid organ injury after blunt abdominal trauma. However, its role in diagnosing hollow viscus injury remains controversial. The aim of our study was to analyze the accuracy of multidetector CT (MDCT) in the diagnosis of bowel injury. Imaging features of surgically proven cases of bowel injury were identified over 8-year period (i.e., from January 2003 to December 2010) and were retrospectively analyzed. There were 32 patients with age range of 3-90 years. There was only one female. Sensitivity of various CT signs specific to bowel injury (i.e., extravasation of contrast and discontinuity of bowel wall) was 15.62, and 28.12%, respectively. While that of signs suggestive of bowel injury were pneumoperitoneum, 62.5%; gas in the vicinity, 40.62%; bowel wall hematoma, 21.87%; bowel wall thickening, 75%; ascites, 78.12%; mesenteric hematoma, 46.87%; and mesenteric stranding, 40.62%. Based on the major and minor signs, a diagnosis of bowel injury could be made in all patients except one. The minor signs showed a higher sensitivity than the major signs. Hence, we recommend that multidetector CT should be used as the modality of choice in case of patients with suspected bowel injury. We also suggest that the minor signs should be given as much importance as the major signs.

Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs

Background

In recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization.

Aim

The purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney.

Results

The management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey.

Posttraumatic contrast-induced acute kidney injury: minimal consequences or significant threat?

BACKGROUND

Recent enthusiasm for the use of iodinated contrast media and progressive adaption of modern imaging techniques suggests an increased risk of contrast-induced acute kidney injury (CIAKI) in trauma patients. We hypothesized that CIAKI incidence would be higher than that previously reported.

METHODS

A 1-year retrospective review of our prospective database was performed. Low-osmolar, nonionic, iodinated intravascular (IV) contrast was used exclusively. CIAKI was defined as serum creatinine>0.5 mg/dL, or >25% increase from baseline within 72 hours of admission. The association between CIAKI and risk factors was explored.

RESULTS

Of 3,775 patients, 1,184 (31.4%) received IV contrast and had baseline and follow-up serum creatinine. Median age was 38 years (range, 18-95 years) and median Injury Severity Score (ISS) was 16. A total of 8% of patients had history of diabetes mellitus. CIAKI was identified in 78 (6.6%). One patient required long-term hemodialysis. In univariable analysis, age>65 years (p=0.01), history of diabetes mellitus (p=0.01), initial creatinine>1.5 mg/dL (p=0.01), ISS≥16 (p=0.04), and initial systolic blood pressure<90 mm Hg (p=0.01) were identified as risk factors for CIAKI. Of note, no association with the dose of IV contrast≥250 mL and CIAKI was identified (p=0.95). A multiple logistic regression model identified higher age, male gender, systolic blood pressure<90 mm Hg, and higher ISS as risk factors for CIAKI. In-hospital mortality was significantly higher in the CIAKI group (9.0% vs. 3.2%, p=0.02). After adjusting for covariates, CIAKI was not significantly associated with in-hospital mortality.

CONCLUSION

Current trauma management places patients at substantial risk for CIAKI, and risk stratification can be assessed by common clinical criteria. IV contrast dose alone is not an independent associated risk factor. How these data would be extrapolated to an older cohort remains to be determined.

Multidetector computed tomography of acute vascular injury in blunt abdominal/pelvic trauma: imaging predictors of treatment

PURPOSE

The purpose of this study was to analyze the multidetector computed tomography (MDCT) morphologic characteristics of non-aortic acute vascular injuries (AVI) in patients with blunt abdominopelvic trauma that predict treatment.

METHODS

CT scans of 65 trauma patients with non-aortic AVI were reviewed. AVI morphology was categorized as linear or round. The organ of involvement, location of hemorrhage, initial size of hematoma, and hemodynamic status were recorded. Expansion rates of the hematoma were calculated in 40 patients who had delayed imaging. Multivariate regression was used to analyze the morphologic features of AVI and treatment.

RESULTS

Patients with linear AVI were four times more likely to require aggressive treatment (surgery or embolization) than those with a round morphology, independent of the hemodynamic status. There was no main effect of the organ involved, location of hemorrhage, initial bleed size, or expansion rate on the probability of aggressive treatment.

CONCLUSION

The location, initial size, and expansion rate of AVI are not significant predictors of aggressive treatment with surgery or embolization. Linear morphology of AVI, however, is more likely to require aggressive treatment than round AVI, independent of the hemodynamic status. Linear AVI likely reflects a spurting jet of active extravasation, whereas round AVI likely represents a pseudoaneurysm or slow bleed.

Retrospective analysis of duodenal injuries: a comprehensive overview

BACKGROUND/AIM

Duodenal injury is an uncommon finding, accounting for about about 3-5% of abdominal trauma, mainly resulting from both penetrating and blunt trauma, and is associated with significant mortality (6-25%) and morbidity (30-60%).

PATIENTS AND METHODS

Retrospective analysis was performed in terms of presentation, management, morbidity and mortality on 14 patients of duodenal injuries out of a total of 172 patients of abdominal trauma attending Subharti Medical College.

RESULTS

Epigastric pain (100%) along with vomiting (100%) is the usual presentation of duodenal injuries in blunt abdominal trauma, especially to the upper abdomen. Computed tomography (CT) was diagnostic in all cases. Isolated duodenal injury is a rare finding and the second part is mostly affected.

CONCLUSION

Duodenal injury should always be suspected in blunt upper abdominal trauma, especially in those presenting with epigastric pain and vomiting. Investigation by CT and early surgical intervention in these patients are valuable tools to reduce the morbidity and mortality.

Literature review of the role of ultrasound, computed tomography, and transcatheter arterial embolization for the treatment of traumatic splenic injuries

Introduction

The spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.

Diagnostics

Improved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.

Angiography and Embolization

The optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.

Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma

INTRODUCTION

Computed tomographic (CT) scans have become invaluable in the management of patients with blunt abdominal trauma. No clear consensus exists on its role in hollow viscus injuries (HVI) and mesenteric injuries (MI). The aim of this study was to correlate operative findings of HVI and MI to findings on pre-operative CT.

METHODS

All patients treated for blunt abdominal trauma at Tan Tock Seng Hospital from January 2003 to January 2008 were reviewed. CT scans were only performed if the patients were haemodynamically stable and indicated. All scans were performed with intravenous contrast using a 4-slice CT scanner from 2003 to December 2004 and a 64-slice CT scanner from January 2005 onwards. All cases with documented HVI/MI that underwent both CT scans and exploratory laparotomy were analysed.

RESULTS

Thirty-one patients formed the study group, with median age of 40 (range, 22-65) years and a significant male (83.9%) predominance. Vehicular-related incidents accounted for 67.7% of the injuries and the median Injury Severity Score (ISS) was 13 (4-50). The 2 commonest findings on CT scans were extra-luminal gas (35.5%) and free fluid without significant solid organ injuries (93.5%). During exploratory laparotomy, perforation of hollow viscus (51.6%) occurred more frequently than suspected from the initial CT findings of extra-luminal gas. Other notable findings included haemoperitoneum (64.5%), and mesenteric tears (67.7%). None of our patients with HVI and MI had a normal pre-operative CT scan.

CONCLUSION

Our study suggests that patients with surgically confirmed HVI and MI found at laparotomy were very likely to have an abnormal pre-operative CT scan. Unexplained free fluid was a very common finding in blunt HVI/MI and is one major indication to consider exploratory laparotomy.

Can lab data be used to reduce abdominal computed tomography (CT) usage in young adults presenting to the emergency department with nontraumatic abdominal pain?

We sought to determine whether laboratory parameters could be found, predictive of a negative abdominal CT scan in young adults with nontraumatic abdominal pain. Following institutional review board approval, we evaluated CT reports of 522 patients, aged 21-35 years old, who presented to the Emergency Department with nontraumatic abdominal pain. Bivariate analyses relating ten laboratory parameters to whether the CT detected a cause for abdominal pain were conducted. A multivariate logistic regression model was then derived, with all variables in the final model significant at p < 0.05. Variables were dichotomized to yield odds ratios and 95% confidence intervals. Of the 522 patients meeting inclusion criteria, 45% had a cause for pain demonstrated by CT. Predictors of a negative CT in men were normal hematocrit and negative urine blood (p = 0.045, p = 0.016, respectively), and in women normal hematocrit, granulocyte percent, and alkaline phosphatase (p = 0.023, p = 0.039, p < 0.0001, respectively). When standard normal values were used to calculate descriptive statistics, only granulocyte percent in women had a significant confidence interval (odds ratio 2.5, confidence interval 1.6-4.0). Among the 208 women with normal granulocyte percent, the final clinical diagnosis was appendicitis, cholecystitis, and diverticulitis, in three, three, and two cases, respectively (4% combined). In summary, no laboratory test was sufficient to offer reassurance that a CT is not necessary in a young adult patient with nontraumatic abdominal pain. Alternative strategies should be considered to decrease the use of CT, and its associated radiation exposure, in young adults with nontraumatic abdominal pain.

Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma

STUDY OBJECTIVE

We derive and validate clinical prediction rules to identify adult patients at very low risk for intra-abdominal injuries after blunt torso trauma.

METHODS

We prospectively enrolled adult patients (>or=18 years old) after blunt torso trauma for whom diagnostic testing for intra-abdominal injury was performed. In the derivation phase, we used binary recursive partitioning to create a rule to identify patients with intra-abdominal injury who were undergoing acute intervention (including therapeutic laparotomy or angiographic embolization) and a separate rule for identifying patients with any intra-abdominal injury present. We considered only clinical variables readily available with acceptable interrater reliability. The prediction rules were then prospectively validated in a separate cohort of patients.

RESULTS

In the derivation phase, we enrolled 3,435 patients, including 311 (9.1%; 95% confidence interval [CI] 8.1% to 10.1%) with intra-abdominal injury and 109 (35.0%; 95% CI 29.7% to 40.6%) with intra-abdominal injury requiring acute intervention. In the validation study, we enrolled 1,595 patients, including 143 (9.0%; 95% CI 7.6% to 10.5%) with intra-abdominal injury. The derived rule for patients with intra-abdominal injuries who were undergoing acute intervention consisted of hypotension, Glasgow Coma Scale (GCS) score less than 14, costal margin tenderness, abdominal tenderness, hematuria level greater than or equal to 25 red blood cells/high powered field, and hematocrit level less than 30% and identified all 44 patients in the validation phase with intra-abdominal injury who were undergoing acute intervention (sensitivity 44/44, 100%; 95% CI 93.4% to 100%). The derived rule for the presence of any intra-abdominal injury consisted of GCS score less than 14, costal margin tenderness, abdominal tenderness, femur fracture, hematuria level greater than or equal to 25 red blood cells/high powered field, hematocrit level less than 30%, and abnormal chest radiograph result (pneumothorax or rib fracture). In the validation phase, the rule for any intra-abdominal injury present had the following test performance: sensitivity 137 of 143 (95.8%; 95% CI 91.1% to 98.4%), specificity 434 of 1,452 (29.9%; 95% CI 27.5% to 32.3%), and negative predictive value 434 of 440 (98.6%; 95% CI 97.1% to 99.5%).

CONCLUSION

These derived and validated clinical prediction rules can aid physicians in the evaluation of adult patients after blunt torso trauma. Patients without any of these variables are at very low risk for having intra-abdominal injury, particularly intra-abdominal injury requiring acute intervention, and are unlikely to benefit from abdominal computed tomography scanning.

Hollow viscus injury

BACKGROUND

Hollow viscus injuries are uncommon and occur in approximately 1% of all blunt trauma patients.

DISCUSSION

These injuries are often not suspected and are difficult to diagnosis. Morbidity and mortality are high, and a negative abdominal computed tomography is not sufficient to rule out these injuries in certain clinical scenarios.

CONCLUSION

Using a case-based approach, the epidemiology and diagnostic pathways to manage hollow viscus injuries are reviewed.