Diagnostic paracentesis in the acute abdomen

Pancreatic trauma in the adult: current knowledge in diagnosis and management

BACKGROUND/AIMS

Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment.

METHODS

The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience.

RESULTS

The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple's procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory.

CONCLUSION

Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.

Blunt abdominal injuries. Diagnostic peritoneal lavage, ultrasonography and computed tomography scanning

The diagnosis of blunt abdominal injuries is one of the most difficult problems in the management of trauma. There is now better understanding of the diagnostic facilities available. Guidelines regarding the use of diagnostic peritoneal lavage, ultrasonography, or computed tomography scanning should be available in the Accident and Emergency department.

Correlation of peritoneal aspiration cytology with acute appendicitis

Fifty-one patients in whom a clinical diagnosis of acute appendicitis had been made underwent peritoneal aspiration cytology (PAC). Thirty-six had a positive result, 11 had a negative result and aspiration failed in four cases. All patients had an appendicectomy and the histological findings were correlated with the PAC results. Thirty-five of the 36 patients with a positive PAC had histologically proven appendicitis. Seven of the 11 patients with a negative result had normal appendices. The sensitivity of PAC for acute appendicitis was 85% and the specificity was 70%. The positive predictive value was found to be 97% and the negative predictive value 60%. Peritoneal aspiration cytology is a useful aid in the diagnosis of acute appendicitis however, a negative result does not exclude this diagnosis.

Modern aids to clinical decision-making in the acute abdomen

Acute abdominal pain continues to provide not only a large workload for the general surgeon but also many diagnostic and management problems. Many different techniques have been introduced over the past two decades to help in the management of the acute abdomen and this review considers their relative claims to become incorporated into the process of clinical decision-making. The evidence in support of formally structured patient interview pathways with or without computer-aided diagnostic programs is now overwhelming and should become routine. Both laparoscopy and peritoneal cytology have an important role to play in the management of patients in whom the decision to operate is in doubt, and a combination of the two would be complementary. Ultrasonography has become increasingly popular for investigating the acute abdomen, and results from specialist centres are impressive. However, the problems of operator variation and the difficulties in providing a 24-h service will probably prevent it from becoming a first-line investigation in most hospitals. Although plain radiography has been available for many years, its routine use in the management of the acute abdomen remains controversial. Recent studies have confirmed that contrast radiography is an important adjunct to decision-making, particularly in the management of large bowel obstruction, and there is increasing evidence to support its use in suspected small bowel obstruction, perforated peptic ulcer and acute diverticular disease.

Fine-catheter aspiration cytology of peritoneal cavity improves decision-making about difficult cases of acute abdominal pain

Fine-catheter aspiration cytology of the peritoneal cavity was successfully undertaken in 25 of 27 hospital inpatients with acute abdominal pain because it was not clear whether they required urgent laparotomy. Cytological specimens were prepared by the cyto-sieve technique. The main test criterion was the percentage of neutrophils in the peritoneal cell sample. The decision before the test about urgent laparotomy was correct in 14 of the 27 patients, whereas the decision after the test was correct in 26 of the 27 patients (p = 0.001). 4 patients were saved unnecessary laparotomy and 8 further delay in laparotomy.

[Emergency peritoneoscopy in blunt abdominal trauma and acute abdomen (author's transl)]

Peritoneoscopy, angiography, and peritoneal lavage are highly reliable methods for the detection of intraabdominal bleedings in blunt abdominal traumas. Acute peritonitis in severely ill patients can easily be detected by peritoneoscopy, but not by other methods. The results of emergency peritoneoscopy in 166 patients with blunt abdominal trauma and 115 patients with suspected peritonitis are reported.

An appraisal of peritoneal lavage in the diagnosis of the acute abdomen

Forty-seven selected patients presenting with acute abdominal symptoms were investigated by examination of the fluid obtained by peritoneal lavage. In 34 patients this confirmed the clinical diagnosis, in 11 it was a more positive help in that it corrected an erroneous clinical diagnosis and in 2 the results of the investigation were misleading.

Traumatic intraperitoneal haemorrhage. Diagnosis by paracentesis and lavage

A method is described for detecting blood in the peritoneal cavity in cases of blunt abdominal trauma. It involves introducing a peritoneal dialysis catheter through a single puncture site in the anterior abdominal wall and in some cases performing lavage. Fifty cases have been investigated by this method and the results are presented.

Diagnostic abdominal paracentesis

Diagnostic abdominal paracentesis was performed in 43 patients in whom the diagnosis was uncertain. It was found to be particularly useful in abdominal pain resulting from trauma. In 12 patients the findings led to their being spared a laparotomy while in several other patients they led to very early diagnosis of the lesion responsible enabling early surgical treatment to be undertaken. A false-negative result was obtained in only one patient. It is concluded that diagnostic abdominal paracentesis is an extremely reliable diagnostic aid and can lead to improved surgical care of the patient with atypical acute abdominal pain.