Angiography and peritoneal lavage in blunt abdominal trauma

[Medical imaging in the management of abdominal trauma]

There is a marked trend toward nonoperative management of abdominal trauma. This has been possible thanks to the advances in imaging and interventional techniques. Computed tomography (CT), angiography, and endoscopic retrograde cholangiopancreatography (ERCP) can guide the nonoperative management of abdominal trauma.

Spleen Injury in Sports

In brief Following injury, stabilized patients who might have suffered significant trauma to the spleen require ongoing clinical assessment coupled with radiographic imaging. CT is the initial method of choice, although radionuclide scintigraphy may be indicated for pregnant patients and for those who have an iodine allergy. The roles of ultrasound, angiography, and abdominal plain film radiography are limited. Abnormalities demonstrated on contrast-enhanced CT studies include spleen laceration, subcapsular hematoma, and hemoperitoneum. Radionuclide scintigraphy will help diagnose splenosis.

Initial evaluation of the patient with blunt abdominal trauma

Unrecognized abdominal injury remains a distressingly frequent cause of preventable death following blunt trauma. Peritoneal signs are often subtle, overshadowed by pain from associated injury, and masked by head trauma or intoxicants. The initial management of the patient with blunt abdominal trauma should parallel the primary survey of airway, breathing, and circulation. Diagnostic peritoneal lavage remains the cornerstone of triage in patients with life-threatening blunt abdominal trauma. The only absolute contraindication to the procedure is an existing indication for laparotomy. Computed tomography is useful as a complementary diagnostic tool in selected patients, and it is the critical test for guiding nonoperative management of known intraperitoneal trauma. Routine ancillary tests for potentially occult injuries include nasogastric-tube placement for ruptures of the left diaphragm, Gastrografin contrast study for duodenum perforation, and pyelography for urologic injury. Ultrasonography may become a valuable tool in the initial assessment of the injured abdomen. Ultimately, the most important principle in the management of blunt abdominal trauma is repeat physical examination by an experienced surgeon.

A perspective on the early management of abdominal trauma

Blunt trauma in Australia is most commonly due to road accidents and is often multisystem in its effect on the body. Whereas some cases of intra-abdominal injury result in massive bleeding, and may be readily diagnosed clinically, many abdominal injuries are difficult to diagnose on initial clinical examination. Delays in treatment can result in otherwise avoidable morbidity and mortality, and the practice of diagnosis by repeated clinical examination over long periods of time is to be condemned in principle. All abdominal injuries can (and should) now be diagnosed and treatment commenced within 2-4 h of admission to hospital. Diagnostic peritoneal lavage (DPL) is the most sensitive indicator of intraperitoneal blood after trauma, and if employed early, and interpreted with a low threshold for positivity, early treatment of all intraperitoneal organ disruption can be undertaken. The best organ-imaging technique available for abdominal trauma is computerized tomography (CT) scan, but it is not as sensitive as DPL in the diagnosis of haemoperitoneum, and its accuracy in defining bowel injury is not proved. Several factors dictate the choice of DPL or CT scan in difficult trauma cases, and these include the stability of the patient, the availability of CT scan, the experience of the treating physician with either modality, the organs most at risk of injury in any case, and the decision to attempt conservative or operative management. In a small number of cases, doubt may still exist after CT and/or DPL, and an early laparotomy remains the 'gold standard' of diagnosis in such situations. In penetrating trauma, laparotomy is indicated if wound exploration shows penetration of the peritoneum.

The natural history of traumatic branch renal artery injury

Between 1979 and 1984, 24 patients with traumatic branch renal artery injuries documented by selective angiography were managed at our center. A total of 7 patients (29 per cent) died of nonurological organ system injury during the initial hospitalization. Of the remaining patients 10 were followed for 1 to 5 years after injury. None of these patients required immediate or delayed surgical intervention for complications, while 2 had hypertension after injury that resolved spontaneously by 1 year. The eventual renal function attained by these patients remained normal, the mean creatinine was 0.9 plus or minus 0.1 mg. per dl. and there were no other urological complications. Patients who sustain branch renal artery injuries should be managed nonoperatively unless they exhibit cardiovascular instability. Excision of ischemic parenchyma is indicated only when intractable hypertension associated with increased renin secretion can be identified.

Peritoneal lavage and angiography in the management of patients with pelvic fractures

One hundred consecutive patients with pelvic fractures who had undergone peritoneal lavage and abdominal and pelvic angiography were retrospectively analyzed. Sixty-four patients with negative lavages were treated successfully without laparotomy despite a 20 percent incidence of subcapsular or intraparenchymal hematomas of the liver or spleen. Thirty percent of the patients with positive peritoneal lavages were successfully managed without laparotomy when abdominal angiography failed to identify a source of active bleeding. Abdominal angiography was 92 percent accurate in predicting the presence or absence of hemorrhage in 25 patients who underwent laparotomy. There were no false-positive angiograms. The overall false-negative rate was 2.12 percent. These occurred in two patients with torn mesenteric vessels. Pelvic angiography identified arterial pelvic bleeding in 18 percent of the patients. Eighty-four percent of patients with major pelvic bleeding had successful embolization with prompt cessation of arterial bleeding. We conclude that abdominal and pelvic angiography can be a useful adjunct to peritoneal lavage in detecting intraperitoneal hemorrhage and can be of therapeutic value for arterial pelvic bleeding.