Multi detector computed tomography in the diagnosis of bowel injury

Iliac ecchymosis, a valuable sign for hollow viscus injuries in blunt pelvic trauma patients

PURPOSE

Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities.

METHODS

We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted.

RESULTS

In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p < 0.001).

CONCLUSION

IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.

Visceral Injuries in Patients with Blunt and Penetrating Abdominal Trauma Presenting to a Tertiary Care Facility in Karachi, Pakistan

Introduction

Abdominal injuries are responsible for 10% of the mortalities due to trauma. Delays in early diagnosis or misdiagnoses are two major reasons for the mortality and morbidity associated with abdominal trauma. The objectives of this study were to determine the frequency of visceral injuries in patients with abdominal trauma and compare the frequency of visceral injuries in patients with blunt and penetrating abdominal trauma.

Methods

We conducted a cross-sectional study from May 2016 to May 2018 of patients presenting to the emergency department (ED) at Jinnah Postgraduate Medical Center in Karachi, Pakistan. Patients were 12 to 65 years old and presented within 24 hours of abdominal trauma. We recorded the type of abdominal visceral injuries, such as liver, spleen, intestine, stomach, mesentery, and pancreas.

Results

The mean patient age was 31 ±13 years. Penetrating trauma was found in most patients (n=72, 51%). Liver injuries were found in 37 patients (26.4%), spleen injuries in 29 patient (20.7%), stomach injuries in eight patients (5.7%), intestine injuries in 67 patients (47.9%), mesentery injuries in 21 patients (15%), and pancreas injuries in nine patients (6.4%). The type of abdominal trauma was found significantly associated with liver injury (p-value 0.021), and intestine injury (p-value <0.001).

Conclusion

Penetrating trauma (51.4%) was more common than blunt trauma (48.5%), and intestines are the most commonly affected by penetrating and blunt trauma injuries (70.1% and 47.8%, respectively). The liver is the most commonly affected (42.85%) in blunt trauma injuries, followed by the spleen (28.5%). The appropriate authorities should consider this information when instituting public health and safety initiatives.

Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: A systematic literature review

BACKGROUND

Computed tomography (CT) diagnostic accuracy for blunt bowel and mesenteric injuries (BBMI) is controversial.

DATA SOURCES

A literature review to compute aggregate CT performance and individual CT sign sensitivity, specificity, and positive predictive value (PPV) for operative BBMI.

CONCLUSIONS

Sensitivity, specificity, and PPV were: overall CT performance 85.3%, 96.1%, 51.4%; abnormal wall enhancement 30.1%, 95.7%, 64.0%; bowel wall discontinuity 22.3%, 99.0%, 87.9%; bowel wall hematoma 22.5%, 100%, 19.5%; bowel wall thickening 35.2%, 96.5%, 32.1%; free air 32.0%, 98.7%, 57.1%; free fluid 65.6%, 85.0%, 25.5%; mesenteric air 27.6%, 99.1%, 85.3%; mesenteric extravasation 22.9%, 99.6%, 73.9%; mesenteric hematoma/fluid 33.9%, 98.7%, 52.8%; mesenteric stranding/streaking 34.3%, 91.8%, 31.6%; mesenteric vessel beading 32.1%, 97.2%, 60.4%; mesenteric vessel termination 31.6%, 97.2%, 63.5%; oral contrast extravasation 10.0%, 100%, 100%; retroperitoneal air 9.4%, 94.9%, 55.6%; and retroperitoneal fluid 44.2%, 49.4%, 38.5%. Sensitivity, specificity, and PPV vary substantially among known signs. Other clinical factors are necessary for comprehensive BBMI identification.

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%.

Multi-slice computed tomography for diagnosis of combined thoracoabdominal injury

PURPOSE

To investigate the diagnostic value of multi-slice computed tomography (MSCT) for combined thoracoabdominal injury.

METHODS

A retrospective study was conducted to analyze the clinical data and MSCT images of 68 patients who sustained a combined thoracoabdominal injury associated with diaphragm rupture, and 18 patients without diaphragm rupture. All the patients were admitted and treated in the Chongqing Emergency Medical Center (a level I trauma center) between July 2005 and February 2014. There were 71 males and 15 females with a mean age of 39.1 years (range 13e88 years). Among the 86 patients, 40 patients suffered a penetrating injury, 46 suffered a blunt injury as a result of road traffic accident in 21 cases, fall from a height in 16, and crushing injury in 9. The MSCT images were retrospectively reviewed by two radiologists. The results of CT diagnosis were compared with surgical findings and/or follow-up results.

RESULTS

Among the 86 cases, diaphragm discontinuity was found in 29 cases, segmental nonrecognition of the diaphragm in 14, diaphragmatic hernia in 21, collar sign in 14, dependent viscera sign in 18, elevated abdominal organs in 21, bowel wall thickening and/or hematoma in 6, and pneumoperitoneum in 8. CT diagnostic accuracy for diaphragm rupture was 88.4% in the right side and 90.7% in the left side. CT diagnostic accuracy for hemopneumothorax, pulmonary contusion, mediastinal hemorrhage, kidney and adrenal gland injuries was 100%, while for liver, spleen and pancreas injuries was 96.5%, 96.5%, 94.2% respectively.

CONCLUSION

To reach an early diagnosis of combined thoracoabdominal injury, surgeons and radiologists should be familiar with all kinds of images which might show signs of diaphragm rupture, such as diaphragm discontinuity, segmental nonrecognition of the diaphragm, dangling diaphragm sign, diaphragm herniation, collar sign, dependent viscera sign, and elevated abdominal organs.

Mesenteric Hematoma: Is there a Role for Selective Management?

Mesenteric hematomas may present as a radiologic finding after blunt abdominal trauma that may be associated with surgically significant mesenteric and/or bowel injury. The question of whether to operate or not to operate on patients with mesenteric hematoma remains a topic of debate, especially with the improved imaging technology. This study sought to identify clinical and radiological characteristics for patient selection for operative management (OM) of mesenteric hematoma. A retrospective review of 33 adults with blunt abdominal trauma and mesenteric hematoma on CT scan (2009–2012) was performed. Patients with other intra-abdominal injuries, penetrating trauma, isolated gastric hematoma, contrast extravasation, extraluminal air, and Glasgow Coma Scale < 14 were excluded. Patients requiring surgical treatment within 24 hours of admission were compared with those who did not using chi-squared test, Fisher's exact test, and t test. Parameters included age, gender, race, Glasgow Coma Scale, vital signs, pain, tenderness, ecchymosis, Injury Severity Score, length of stay, and inhospital mortality. Logistic regression was used to determine positive associations with OM. Of the 33 patients, 19 underwent OM and 14 did not. Both groups were similar at baseline. Regression analysis revealed association for pain [odds ratio (OR) = 9.6, confidence interval (CI) = 1.8–49.9, P < 0.01], tenderness (OR = 32, CI = 4.6–222.2, P < 0.01), and free fluid (OR = 10.3, CI = 1.8–60, P < 0.01) with need for operative intervention. Nonoperative management patients had 100 per cent success rate. Of the OM patients, 100 per cent underwent therapeutic laparotomies. Findings of mesenteric hematoma on CT scan in examinable patients with no abdominal pain, tenderness, or free fluid predict successful nonoperative management.

Characteristics of Hollow Viscus Injury following Blunt Abdominal Trauma; a Single Centre Experience from Eastern India

OBJECTIVE

To determine the presentation, anatomical distribution, diagnostic method, management and outcome of hollow viscus injury (HVI) from blunt abdominal trauma.

METHODS

This  was  a  retrospective  cross-ecnal  study  including  patients  with  blunt  abdominal  trauma leading to HVI admitted at Rajendra Institute of Medical Sciences, Ranchi, over a period of 4.5 years (January 2009 to July 2014). Data were retrieved from patients' medical records. Total 173 patients with HVI due to blunt abdominal trauma, who underwent laparotomy at our institute, were reviewed. Data regarding clinical presentation, anatomical distribution, management and outcome were recorded and analysed.

RESULTS

Out of 173 patients 87.1% were men and 12.9% were women. Mean age of patients was 29±14.02 years. The most common site of injury was ileum (46.2%) followed by jejunum (44.5%). There were 5 gastric perforations (2.9%), 2 (1.15%) duodenal, 2 (1.15%) colonic, 2 (1.15%) sigmoidal and 2 (1.15%) rectal injuries. One caecal injury was also recorded. Road traffic accident was the most common mechanism of injury (57.2%) followed by fall from height (36.4%) and assault (6.4%). Free gas under diaphragm on erect abdomen radiography was seen in 85.5% of cases while preoperative CT Abdomen was done in 11.6% of cases. Treatment consisted of simple closure of the perforation (66.5%), resection and anastomosis (11.0%) and stoma (22.5%). Major complication was anastamotic leak which was recorded in 6.4% cases and 15.6% patients developed burst abdomen. Average hospital stay was 13±6 days. Overall mortality rate was 12.7%.

CONCLUSION

Although early recognition of intestinal injuries from blunt abdominal trauma may be difficult in all cases, it is very important due to its tremendous life threatening potential. Age of the patient, anatomical site and time of presentation are probably main prognostic factors.

Non operative management of abdominal trauma - a 10 years review

INTRODUCTION

Due to high rate of operative mortality and morbidity non-operative management of blunt liver and spleen trauma was widely accepted in stable pediatric patients, but the general surgeons were skeptical to adopt it for adults. The current study is analysis of so far largest sample (1071) of hemodynamically stable blunt liver, spleen, kidney and pancreatic trauma patients managed non operatively irrespective of severity of a single /multiple solid organ injury or other associated injuries with high rate of success.

METHODS

Experience of 1071 blunt abdominal trauma patients treated by NOM at a tertiary care National Trauma Centre in Oman (from Jan 2001 to Dec 2011) was reviewed, analyzed to determine the indications, methods and results of NOM. Hemodynamic stability along with ultra sound, CT scan and repeated clinical examination were the sheet anchors of NOM. The patients were grouped as (1) managed by NOM successfully, (2) failure of NOM and (3) directly subjected to surgery.

RESULTS

During the 10 year period, 5400 polytrauma patients were evaluated for abdominal trauma of which 1285 had abdominal injuries, the largest sample study till date. Based on initial findings 1071 patients were admitted for NOM. Out of 1071 patients initially selected 963 (89.91%) were managed non operatively, the remaining 108 (10.08%) were subjected to laparotomy due to failure of NOM. Laparotomy was performed on 214(19.98%) patients as they were unstable on admission or had evidence of hollow viscous injury.

CONCLUSION

NOM for blunt abdominal injuries was found to be highly successful in 89.98% of the patients in our study. Management depended on clinical and hemodynamic stability of the patient. A patient under NOM should be admitted to intensive care / high dependency for at least 48-72 hours for close monitoring of vital signs, repeated clinical examinations and follow up investigations as indicated.