Original ContributionCombination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration
Introduction
In trauma patients, when blunt abdominal injuries occur, the liver is the second most commonly injured organ [1]. When patients present with less significant or occult blunt abdominal trauma in an emergency department (ED), it is sometimes difficult to determine whether further examination is needed to diagnosis whether there is liver laceration.
Although right upper quadrant pain during physical examination may indicate hepatic injury in conscious patients, this is still a fairly unreliable indicator of injury even in skilled and experienced hands [1], [2], [3], [4], [5], [6]. Focused abdominal sonography for trauma (FAST) can sensitively detect free fluid in the abdomen and pelvis [7], [8], [9]. However, the positive rate is about 64% sensitivity for documented injuries in a previous study [10]. When there are parenchymal injuries of liver only, with no free fluid, the sensitivity will be even lower [2]. Therefore, routine abdominal computed tomographic (CT) scans have been suggested for hemodynamic stable patients with suspicious blunt abdominal trauma [11].
In Taiwan and throughout many Western Counties, most patients with abdominal injuries arrive at the EDs of district general hospitals that are equipped with CT. However, in many parts of the world, CT scanning is readily available in urban areas but not in rural and remote areas—for example, Australia, Africa, and India have substantial variability in the distance to CT facilities [12]. In addition, considering the potential risks carried in the CT imaging study, including possible renal toxicity of and allergic reaction to the contrast or the potentially adverse effect of the radiation dosage, especially in a pregnant woman, it is difficult to determine whether obtaining CT scans in these patients is advisable. Therefore, it would be desirable to identify some factors that can help to make this decision and initiate prompt treatment of abdominal injury.
Various pediatric studies have investigated the association between liver enzymes and hepatic injuries [13], [14], [15], [16]. Another study found an association between WBC count and intraabdominal injury [17]. However, WBC count is considered to be nonspecific and has never been described as a possible diagnostic indicator of liver laceration.
Combining hepatic enzymes and WBC counts to predict hepatic injury is common practice among pediatric surgeons and by some adult trauma surgeons as well. However, the relevance of these is that this known clinical observation has not had significant published data to support it. Therefore, we retrospectively reviewed liver laceration patients and analyzed the differences of WBC counts and hepatic enzymes in the initial laboratory workup. We attempted to make clear whether WBC counts could help predict liver laceration when used in conjunction with liver enzymes.
Section snippets
Study design
In this retrospective case-control study, we studied the records of all visitors to the ED for blunt abdominal injuries generated from our trauma registry. The data were collected from a 1200-bed hospital in southern Taiwan and were reviewed. The study hospital is a university teaching hospital that provides health care service to approximately 1.5 million people within the Kaohsiung metropolitan area and has more than 80 000 visits to the ED annually. Although fully equipped with level I
Characteristics of study sample
In total, during the study period, 289 patients were admitted to our ED and received enhanced abdominal CT scans. Forty-two of these patients were diagnosed as having liver laceration at discharge and could not be excluded for any of the reasons described above. These 42 patients were assigned to the study group, which consisted of males and females ranging equally in age from 3 to 91 years old. The controls were recruited from the same 289 patients admitted for abdominal blunt trauma, having
Discussion
In the ED, patients sustaining blunt abdominal trauma with liver laceration may present with unstable hemodynamics and obvious hemoperitoneum. These patients do not bring diagnostic challenges because the strategy is clear. They generally receive prompt abdominal radiography studies that clearly illustrate the injuries after celiotomy for lesion repair or damage controls in the operation room. However, in some circumstances, the liver lacerations were less significant or occult, making the
Limitations
Although this study is a retrospective study, there might be some limitations. Although liver enzymes have significant difference between liver laceration or without, they may be confounded by the presence of hepatitis or by the time that blood is drawn. However, we tried to exclude patients who had medical history of hepatitis and confined our patients to the group having their blood drawn within 6 hours to reduce the study bias. In fact, with this effort and the short transport time from
Conclusion
In conclusion, this study suggests that, in patients sustaining blunt abdominal trauma, concomitant serum levels of AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10 000/mm3 strongly indicate liver laceration, and more active diagnostic strategy should be taken.
References (22)
- et al.
Injuries distracting from intraabdominal injuries after blunt trauma
Am J Emerg Med
(1998) - et al.
The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study
Injury
(1997) - et al.
Management of patients with head injury
Lancet
(2008) - et al.
The role of elevated liver transaminase levels in children with blunt abdominal trauma
Injury
(2003) - et al.
Blunt abdominal injury: serum ALT-A marker of liver injury and a guide to assessment of its severity
Injury
(2007) - et al.
Non-operative management of blunt hepatic trauma
Br J Surg
(1998) - et al.
Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury
J Trauma
(1999) - et al.
Intra-abdominal injury following blunt trauma. Identifying the high-risk patient using objective risk factors
Arch Surg
(1989) - et al.
Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries
J Trauma
(1999) - et al.
Diagnostic value of ultrasonography in the evaluation of blunt abdominal trauma
Diagn Interv Radiol
(2005)
Blunt abdominal trauma: screening us in 2,693 patients
Radiology
Cited by (23)
Clinical Chemistry, Immunology and Laboratory Quality Control: A Comprehensive Review for Board Preparation, Certification and Clinical Practice
2021, Clinical Chemistry, Immunology and Laboratory Quality Control: A Comprehensive Review for Board Preparation, Certification and Clinical PracticeAmeliorative effect of supercritical fluid extract of Chrysanthemum indicum Linnén against D-galactose induced brain and liver injury in senescent mice via suppression of oxidative stress, inflammation and apoptosis
2019, Journal of EthnopharmacologyCitation Excerpt :To summarize, the results of histopathological evaluation suggested that CISCFE remarkably improved the D-gal-induced morphological and histological alterations in mice liver and might exert a favorable hepatoprotective effect against D-gal-induced toxicity. Serum levels of ALT and AST have been acknowledged as key indicators to evaluate the degree of liver damage in clinical findings (Lee et al., 2010). An increase in these marker enzymatic activities is owing to the leakage of the enzymes from liver cells as a result of tissue injury.
The predictive value of biochemical parameters in evaluating patients with abdominal trauma: The new scoring system
2017, Turkish Journal of Emergency MedicineCitation Excerpt :Also in that study, it was found that normal levels of serum ALT, AST and LDH excluded the possibility of serious liver injury.7 Among 289 patients who underwent abdominal CT screening due to blunt abdominal trauma, Lee et al.17 proposed that increased white blood cell counts together with elevated levels of serum ALT and AST were determined to be cogent rationales for the use of screening methods to investigate for liver injury.17 The findings of our study with respect to the relationship between ALT and AST levels and intraabdominal injury are consistent with the literature.
Toxicity assessment due to sub-chronic exposure to individual and mixtures of four toxic heavy metals
2015, Journal of Hazardous MaterialsCitation Excerpt :Further, there were significant increases in WBC and LDL (Pb + Hg + Cd only) during the 30-day study. Elevated WBC was due to the immune system’s response to combat insults from causative agent’s [57,58]. High LDL, which may suggest abnormal lipid metabolism, could be oxidized in the form of cholesteryl-linoleate in conditions such as atherosclerosis or inflammatory diseases such as rheumatoid arthritis in humans [59].
Predictive value of liver transaminases levels in abdominal trauma
2014, American Journal of Emergency MedicineCitation Excerpt :However Lee et al have shown a cut off level for liver laceration in patient who had abdominal trauma. In their study they have found that elevations of serum AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10 000/mm3 with a sensitivity and specificity of 90.0% and 92.3%, respectively, in the 42 liver laceration victims [14]. Also Stassen et al have shown that patients with an admission AST level > 360 IU/L and a FAST with negative findings had a 88% chance of having any grade hepatic injury and a 44% chance of having a hepatic injury of grade III or greater, Patients with an AST level of < 360 IU/L and a FAST with negative findings only had a 14% chance of having a liver injury and no chance of having an injury of grade III or greater [2].
Hepatoprotective effects of Adenanthera pavonina (Linn.) against anti-tubercular drugs-induced hepatotoxicity in rats
2013, Pharmacognosy JournalCitation Excerpt :Hepatocellular disintegrate and the inflammation in the liver was observed in the centrilobular region by histopathological examination in INH + RIF treated groups. This could be only possible by the overall protective character of the extract.30–32 A plethora of reports has been published that flavonoids, alkaloids and saponins played a major role in protecting the liver from injuries.