Original Contribution
Combination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration

https://doi.org/10.1016/j.ajem.2009.06.005Get rights and content

Abstract

Background

It is sometimes difficult to decide whether to perform abdominal computed tomographic (CT) scans for possible liver laceration in patients who have sustained less severe or minor blunt abdominal trauma. This study was conducted to find out whether the basic laboratory workup could provide information of possible liver laceration in blunt abdominal trauma patients and act as an indication for CT scans.

Methods

In this retrospective case-control study, we included 289 patients who had sustained blunt abdominal injury for which they received abdominal CT scans in our emergency department. Of the 289 patients, the study group (n = 42) included patients who had been found to have liver lacerations after obtaining the CT; the controls (n = 42) were those not found to have such injuries by the same method with matching of age and sex.

Results

In patients with blunt abdominal injuries, there is a strong difference in liver laceration between elevation of white blood cell (WBC) counts (P = .001), aspartate aminotransferase (AST) (P < .001), and alanine aminotransferase (ALT) (P < .001). A logistic regression model demonstrated that WBC count and AST were independently associated with liver laceration. With elevations of serum AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10 000/mm3, we found a sensitivity and specificity of 90.0% and 92.3%, respectively, in the 42 liver laceration victims.

Conclusion

In patients with blunt abdominal trauma, elevated WBC counts together with elevated AST and ALT are strongly associated with liver laceration and warrant further imaging studies and management.

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.

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