Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy

doi:10.1016/S0002-9610(01)00665-1

The American Journal of Surgery

Volume 182, Issue 1, July 2001, Pages 6-9

https://doi.org/10.1016/S0002-9610(01)00665-1 Get rights and content

Abstract

Background: Mandatory celiotomy has been proposed for all patients with unexplained free fluid on abdominal computed tomography (CT) scanning after blunt abdominal injury. This recommendation has been based upon retrospective data and concerns over the potential morbidity from the late diagnosis of blunt intestinal injury. This study examined the rate of intestinal injury in patients with free fluid on abdominal CT after blunt abdominal trauma.

Methods: This study was a multicenter prospective series of all patients with blunt abdominal trauma admitted to four level I trauma centers over 22 months. Data were collected concurrently at the time of patient enrollment and included demographics, injury severity score, findings on CT scan, and presence or absence of blunt intestinal injury. This database was specifically queried for those patients who had free fluid without solid organ injury.

Results: In all, 2,299 patients were evaluated. Free fluid was present in 265. Of these, 90 patients had isolated free fluid with only 7 having a blunt intestinal injury. Conversely, 91% of patients with free fluid did not. All patients with free fluid were observed for a mean of 8 days (95% confidence interval 6.1 to 10.4, range 1 to 131). There were no missed injuries.

Conclusions: Free fluid on abdominal CT scan does not mandate celiotomy. Serial observation with the possible use of other adjunctive tests is recommended.

Section snippets

Methods

The methods and patient selection has been described in detail previously [13]. Briefly, all patients admitted to four level I trauma centers after blunt abdominal trauma between November 1994 and September 1996 were evaluated. Exclusion criteria included patients <16 years of age, who required an emergency celiotomy prior to diagnostic testing, or had a Glasgow Coma Scale (GCS) score <14. All data were collected concurrently at the time of patient enrollment into the study.

All patients

Results

A total of 2,299 patients underwent both a physical examination and an abdominal CT scan within 12 hours of admission and formed the study group. There were 1,558 men and 741 women with a mean age of 36 years. The mechanism of injury included motor vehicle crashes (1,432), pedestrian struck (264), falls (198), assault (154), and motorcycle crashes (147). There were no significant differences in enrollment between centers.

Three hundred and eighty-nine (17%) patients had a positive abdominal CT

Comments

The optimal management of the trauma patient who has free fluid without solid organ injury on an abdominal CT remains controversial, with many investigators advocating mandatory celiotomy [2], [3], [4]. This controversy is, in part, due to the lack of large series of prospectively collected data from which to formulate a treatment plan. The data presented here clearly demonstrate that mandatory celiotomy patients with free fluid but without solid organ injury on an abdominal CT is not

Acknowledgements

Supported by Agency for Health Care Policy Research grant RO1-HS07336.

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We systematically reviewed the PubMed and SCOPUS databases from 2000 to 2020. The primary outcome of interest was identification of significant intra-abdominal injuries requiring therapeutic laparotomy. We performed the meta-analysis using a random-effects model.
Eight studies involving 7763 patients were evaluated. Isolated free fluid was present in 722 (9.3%) patients. Their median age was 35.82 years, and their average Injury Severity Score was 17.1. The major mechanism of injury was motor vehicle accidents (31.2%). Of 722 patients, 490 underwent initial NOM and 232 underwent immediate laparotomy. The success rate of initial NOM was 98% [95% confidence interval (CI), 0.959–1.002]. The failure rate of initial NOM was 7.4% (95% CI, 0.023–0.126). Significant intra-abdominal injuries were identified in 39.2% of patients (95% CI, 0.127–0.657). Most of the significant intra-abdominal organ injuries were mesenteric injury in 23% of patients (95% CI, −0.004–0.463) and bowel injury in 18.4% (95% CI, 0.098–0.271). A moderate to large amount of fluid on computed tomography and abdominal tenderness were associated with laparotomy (p = 0.000 and 0.040, respectively), but neither was a significant risk factor for therapeutic laparotomy or significant intra-abdominal injury.
Isolated free fluid following blunt abdominal injury in hemodynamically stable patients does not mandate immediate or delayed laparotomy. Initial NOM can be considered with hemodynamic monitoring of early warning signs of sepsis (e.g., using the Quick Sequential Organ Failure Assessment), and serial abdominal examination might help to detect significant intra-abdominal injury requiring therapeutic laparotomy. In patients suspected to have injury after initial NOM and in patients who cannot cooperate, diagnostic laparoscopy will play an important role in minimally invasive diagnosis.
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Surgeon members of the Eastern Association for the Surgery of Trauma and American Pediatric Surgical Association completed a survey on 3 blunt abdominal injury scenarios: (1) isolated, (2) with multisystem injury, and (3) with traumatic brain injury (TBI), and a penetrating injury scenario. Multivariable logistic regression was used to determine factors associated with initial management of observation vs. operation for blunt injury and observation vs. local wound exploration versus laparoscopy for penetrating injury.
Of 394 surgeons (response rate 22.3%), 50.3% were pediatric surgeons. For scenarios 1–3, 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78–2.72) or TBI (aOR 3.60, 95%CI: 2.79–4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22–0.44). For penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively.
Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care.
Cross-Sectional Survey.
N/A
Educational Review of Predictive Value and Findings of Computed Tomography Scan in Diagnosing Bowel and Mesenteric Injuries After Blunt Trauma: Correlation With Trauma Surgery Findings in 163 Patients
2017, Canadian Association of Radiologists Journal
Laparotomy can detect bowel and mesenteric injuries in 1.2%–5% of patients following blunt abdominal trauma. Delayed diagnosis in such cases is strongly related to increased risk of ongoing sepsis, with subsequent higher morbidity and mortality. Computed tomography (CT) scanning is the gold standard in the evaluation of blunt abdominal trauma, being accurate in the diagnosis of bowel and mesenteric injuries in case of hemodynamically stable trauma patients. Aims of the present study are to 1) review the correlation between CT signs and intraoperative findings in case of bowel and mesenteric injuries following blunt abdominal trauma, analysing the correlation between radiological features and intraoperative findings from our experience on 25 trauma patients with small bowel and mesenteric injuries (SBMI); 2) identify the diagnostic specificity of those signs found at CT with practical considerations on the following clinical management; and 3) distinguish the bowel and mesenteric injuries requiring immediate surgical intervention from those amenable to initial nonoperative management.
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Multidetector CT scan is the gold standard in the assessment of intra-abdominal blunt abdominal trauma for not only parenchymal organs injuries but also detecting SBMI; in the presence of specific signs it provides an accurate assessment of hollow viscus injuries, helping the trauma surgeons to choose the correct initial clinical management.
La laparotomie permet de détecter les lésions traumatiques de l'intestin et du mésentère chez 1,2 % à 5 % des patients qui ont subi un trauma abdominal fermé. Dans de tels cas, un diagnostic tardif est fortement associé à un risque accru de sepsie persistante et à des taux plus élevés de morbidité et de mortalité. La tomodensitométrie (TDM) est la modalité de référence pour l'évaluation des traumas abdominaux fermés, pour un diagnostic exact des lésions traumatiques de l'intestin et du mésentère chez les patients victimes de traumatismes et stables sur le plan hémodynamique. Les buts de la présente étude sont les suivants: 1) examiner la corrélation entre les signes de la TDM et les observations peropératoires dans les cas de lésions traumatiques de l'intestin et du mésentère par suite de trauma abdominal fermé et analyser la corrélation entre les facteurs radiologiques et les observations peropératoires tirées de notre expérience auprès de 25 patients victimes de traumatismes avec lésions de l'intestin grêle et du mésentère; 2) établir la spécificité de diagnostic des signes trouvés lors de la TDM ayant des considérations pratiques pour la gestion clinique subséquente; 3) distinguer les lésions traumatiques de l'intestin et du mésentère nécessitant une intervention chirurgicale immédiate des lésions pouvant initialement être prises en charge de façon non chirurgicale.
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Citation Excerpt :
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In hemodynamically stable patients who had (FIAF) on abdominal CT scan with SOI, a non-operative approach is usually considered. However, the management of patients with detectable FIAF without an obvious SOI is a challenging task for surgeons [4,6,7]. Although, there is contemporary advancement in imaging modalities with multi-detector computed tomography (MDCT), the diagnosis and interpretation of such injuries remains difficult or delayed [8,9].
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Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy

Abstract

Section snippets

Methods

Results

Comments

Acknowledgements

Isolated free fluid on abdominal computerized tomographic scanan indication for surgery in blunt trauma patient?

Conn Med

Does free fluid on abdominal CT scan after blunt trauma require laparotomy?

J Trauma

Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma

J Trauma

Diagnosis and management of blunt small bowel injurya survey of the membership of the American Association for the Surgery of Trauma

J Trauma

New diagnostic peritoneal lavage criteria for diagnosis of intestinal injury

J Trauma

Small bowel perforationis urgent surgery necessary?

J Trauma

Hollow visceral injury and blunt trauma

J Trauma

Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injuryan analysis of time to operative intervention in 198 patients from a multicenter experience

J Trauma

Negative laparotomymortality and morbidity among 100 patients

Am Surg