Diagnosis Of Hollow Viscus Injury Research Articles

Application of Computed Tomography in the Identification of Hollow Viscus Injuries in Blunt Trauma Patients

Purpose: Despite advances in diagnostic and imaging technologies, the diagnosis of traumatic hollow viscus injury (HVI) remains a great challenge in clinical practice. This study aimed to determine the accuracy of computed tomography (CT) in the diagnosis of HVI in emergent blunt trauma patients.Methods: The study was conducted on patients with abdominal trauma who were admitted to our center, regional emergency center, Kyung Hee University Medical Center, between January 2008 and December 2018. The clinical data of patients with abdominal trauma who underwent CT and abdominal surgery within 24 hours of hospitalization were analyzed to determine the diagnostic capacity of CT.Results: In total, 156 patients were included in the study. There were 88 cases of blunt trauma. Among these patients, 27 were diagnosed with HVI using CT, and 38 patients were diagnosed with HVI in the operating room. The median injury severity score for these patients was 10.0, the revised trauma score was 7.841, and the trauma injury severity score was 0.96. The sensitivity and specificity of CT in predicting HVI in these patients were 65.8%, and 96.0%, respectively. The positive and negative predictive values were 92.6%, and 78.7%, respectively.Conclusion: In urgent situations, CT findings alone are insufficient for diagnosing HVI. Further research on the HVI diagnostic capacity of CT is required.

Evaluation of the Viscus injury in Abdominal Trauma

Background: The diagnosis of hollow viscus injury with advanced diagnostic tools and management of trauma by conservative and surgically by laparotomy and correction of anatomy. Hence such injuries are frequently overlooked leading to increased morbidity and mortality. Thus, this study is intended to throw light upon the prompt diagnosis and management of hollow viscus injuries in trauma. Hence the aim of the present research was to study the diagnosis and management of hollow viscus injuries. Subjects and Methods: A total of 100 cases were included in the study. All the patients were above the age of 11 years and maximum age of 80 years. Most of the patients included were male with ration of 4:1. After recording of history clinical examination followed by radiological, serological and operative findings were recorded. Data was analyse to study the male: female ratio, etiologies of viscous injury, investigation done and possible management for the treatment. Results: On analysis of the data, most common reason for the abdominal trauma was found to be road traffic accident followed by stab injury. The maximum of the patients belong to the age group of 2 to 30 years. Most common reason for the abdominal trauma was found to be road traffic accident followed by stab injury. Conclusion: It is mostly seen in the age group of 21-30 years which form the young and reproductive group. These patients’ measures should be taken to prevent these accidents and care of victims at the accident site. Well established trauma care centers should be established at least at every taluk hospital. Measures for early transport of the patients from the accident site to the trauma care centres to be undertaken.

Injuries to the Stomach, Small Bowel, Colon, and Rectum

Hollow viscus injury is most often the consequence of penetrating abdominal trauma. As a result of blunt force trauma, bowel injury occurs with relative infrequency: in one multi-institutional analysis, only 1.2% of blunt trauma admissions had an associated hollow viscus injury. The diagnosis of hollow viscus injury remains a challenge in abdominal trauma patients, and subsequent evaluation is determined by the mechanism of injury. Regardless of the specific injury mechanism, however, the principles and techniques of operative management are largely the same. This review covers determination of need for operation, and operative management. Figures show algorithms outlining the evaluation of blunt hollow organ injury in a hemodynamically stable patient with an unreliable physical examination, the treatment of truncal stab wounds, the treatment of blunt bowel and mesenteric injury, the treatment of gastric injury, the treatment of small bowel injury, the treatment of colon injury, the treatment of rectosigmoid or rectal injury, and a demonstration of presacral drainage through a curved incision midway between the anus and the tip of the coccyx. Tables list the incidence of findings suggestive of blunt mesenteric and bowel injury in true positive and false positive computed tomography scans, and the American Association for the Surgery of Trauma organ injury scales for gastrointestinal tract and pancreas. This review contains 8 figures, 3 tables, and 58 references Keywords: Injury, blunt, primary rectal repair, colostomy, laparotomy, trauma

Diagnostic performance of CT and the use of GI contrast material for detection of hollow viscus injury after penetrating abdominal trauma. Experience from a level 1 Nordic trauma center.

Use of gastrointestinal (GI) contrast material for computed tomography (CT) diagnosis of hollow viscus injury (HVI) after penetrating abdominal trauma is still controversial. To assess the sensitivity of CT and GI contrast material use in detecting HVI after penetrating abdominal trauma. Retrospective analysis (2013-2016) of patients with penetrating abdominal trauma. Data from the local trauma registry, medical records, and imaging from PACS were reviewed. CT and surgical findings were compared. Of 636 patients with penetrating trauma, 177 (163 men, 14 women) had abdominal trauma (mean age 34 years, age range 16-88 years): 155/177 (85%) were imaged with CT on arrival; 128/155 (83%) were stab wounds and 21/155 (14%) were gunshot wounds; 47/155 (30%) had emergent surgery after CT. Two patients were imaged using oral, rectal and i.v. contrast; 23 with rectal and i.v. contrast; and 22 with i.v. contrast only. Surgery revealed HVI in 26 patients. CT had an overall sensitivity 69.2%, specificity 90.5%, PPV 90.0%, and NPV 70.4%. CT with oral and/or rectal contrast (n = 25) had sensitivity 66.7%, specificity 71.4%, PPV 85.7%, and NPV 45.5%. CT with i.v. contrast only (n = 22) had 75% sensitivity, 100% specificity, PPV 100%, and NPV 87.5%. No statistically significant difference was found between sensitivity of CT with GI contrast material and i.v. contrast only (P = 1). Stab wounds were the most common cause of penetrating abdominal trauma. CT had 69.2% sensitivity and 90.5% specificity in detecting HVI. CT with GI contrast had similar sensitivity as CT with i.v. contrast only.

Conservative management of penetrating abdominal trauma (stab wound)

Background: The aim of the study is to study the reliability of selective conservative management of the penetrating stab abdominal wounds. Trauma is one of the most important reasons of mortality. The mechanism that underlies the penetrating trauma relates to the mode of injury. The early diagnosis of hollow viscus injuries is difficult and a delay in the diagnosis of such injuries may be associated with increased morbidity and mortality. Focused assessment with sonography for trauma (FAST) is an effective for screening and initial classification of stable patients and confirmed by CT scan. The management of stable patients was either surgical exploration or selective non-operative interference with the optimal management of patients is yet to be fully elucidated for abdominal stab wounds (ASW).Methods: A prospective study of 40 patients with penetrating abdominal stab wounds between June 2017 and February 2018, at Damanhour Medical National Institute.Results: The mean age of our patients was 51.9±13.3 years with predominance of males and without predominance of any side to be affected and non-significant deviation from the normal values of hemodynamic signs. The presence of air under diaphragm in X-ray films signify abdominal penetration and ultrasonographic examination (FAST) document the diagnosis and help in following up of cases. Most of hemodynamically stable patients passed conservatively with a little rate of laparotomy.Conclusions: We concluded that there is still a role for conservative management in managing stable cases of penetrating stab abdominal wound.

Early diagnosis of hollow viscus injury using intestinal fatty acid-binding protein in blunt trauma patients.

A delay in diagnosing hollow viscus injury (HVI) causes an increase in mortality and morbidity. HVI remains a challenge to diagnose, and there is no specific diagnostic biomarker for HVI. We evaluated the utility of intestinal fatty acid–binding protein (I-FABP) in diagnosing HVI in blunt trauma patients. Within a 5-year period, 93 consecutive patients with clinically suspected HVI at our trauma center were prospectively enrolled. The diagnostic performance of I-FABP for HVI was compared with that of other various parameters (physical, laboratory, and radiographic findings). HVI was diagnosed in 13 patients (14%), and non-HVI was diagnosed in 80 patients (86%). The level of I-FABP was significantly higher in patients with HVI than in those with non-HVI (P = 0.014; area under the curve, 0.71). The sensitivity, specificity, positive predictive value, and negative predictive value were 76.9%, 70.0%, 29.4%, and 94.9%, respectively (P = 0.003). However, all other biomarkers were not significantly different between the groups. Presence of extraluminal air, bowel wall thickening on computed tomography (CT), and peritonitis signs were significantly higher in patients with HVI (P < 0.05). Of 49 patients (52.7%) who had a negative I-FABP and negative peritonitis signs, none developed HVI (sensitivity, 100%; negative predictive value, 100%). This is the first study that demonstrated the diagnostic value of a biomarker for HVI. I-FABP has a higher negative predictive value compared to traditional diagnostic tests. Although the accuracy of I-FABP alone was insufficient, the combination of I-FABP and other findings can enhance diagnostic ability.

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: An analysis of a National Trauma Registry database

IntroductionNon-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. MethodsA retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. ResultsOf the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. ConclusionsThe presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.

Non-operative Management in Penetrating Abdominal Trauma: IS it Feasible at a Level II Trauma Center?

BackgroundThe recent mandate for surgical exploration for all penetrating abdominal trauma has been questioned. High-volume centers report good outcomes for non-operative treatment in penetrating trauma for hemodynamically stable patients without peritonitis and with tangential wounds. The applicability of this strategy in smaller hospitals is unknown. Study ObjectivesThe purpose of this study was to evaluate non-operative management of penetrating abdominal trauma at a Level II trauma center. MethodsWe retrospectively reviewed all patients with penetrating abdominal trauma from 2006 through 2008. Demographic information, treatments, and outcomes were analyzed using descriptive statistics. ResultsOur sample consisted of 86 patients with penetrating abdominal trauma; 12 (14%) had documented peritoneal violation and were managed non-operatively. The average age was 30 years (range 21–39 years), with 50% African American, 33% Caucasian, and 17% Hispanic. Male patients accounted for 92%, and the average Injury Severity Score was 5.2 (range 1–13). Overall non-operative treatment failed in 3 patients (25%); one required drainage of a retrogastric abscess on hospital day 4, and another underwent gastric and diaphragm repair on hospital day 1. The third treatment failure did not require an operation but developed a biloma requiring percutaneous drainage. There were no other complications related to non-operative therapy and no mortalities. The average length of stay was 3.9 days; 83% of patients were discharged home. ConclusionsIn hemodynamically stable patients without peritonitis and documented isolated injuries to solid organs, non-operative management of penetrating abdominal trauma seems safe; however, it can delay diagnosis of hollow viscus injuries. Until further data emerge, extreme caution should be used in employing non-operative management for penetrating abdominal injuries at small trauma centers.

Laparoscopy in penetrating abdominal trauma

BACKGROUND: Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. There is no doubt that persistent hemodynamic instability or signs of peritoneal irritation warrant immediate laparotomy. If the patient is hemodynamically stable and has equivocal abdominal examination findings, diagnosis may be obtained by laparoscopy. METHODS: The goal of this article is to evaluate the role of laparoscopy in the management of PAT. RESULTS: Patients with penetrating trauma to the thoracoabdominal and anterior abdominal wall are good candidates for laparoscopic evaluation. The peritoneal cavity and its contents, including the retroperitoneal space, can be thoroughly examined easily and safely. The main benefits of laparoscopy include the reduction of nontherapeutic laparotomies, identification of mostly intra-abdominal injury, and provision of potential therapy for some cases. Diagnostic laparoscopy has a high overall diagnostic accuracy, reduced morbidity, and shortened hospital stay and is also cost-effective. While laparoscopy has some limitations in the diagnosis of hollow viscus injury, it can detect and repair diaphragmatic injuries accurately and exclude the risk of nontherapeutic laparotomy due to a nonbleeding injury of the solid organs. CONCLUSIONS: The use of laparoscopy as a diagnostic or therapeutic method in patients with PAT is reserved only for hemodynamically stable patients and uncertain findings of peritonitis. Laparoscopy is an efficient and effective diagnostic tool when used by a well-trained surgeon. With experience, an increasing number of surgeons are using laparoscopy as an additional diagnostic tool for PAT in stable patients. With more experience and skills, laparoscopy may be used more therapeutically in selected patients. Minimally invasive surgery has already established itself as a useful tool in the management of PAT. The future seems to be promising for this field of surgery by innovative developments in computer technology and robotic systems.

Delay in Diagnosis of Hollow Viscus Injuries: Effect on Outcome

Delay in the recognition of hollow viscus injury may lead to increased morbidity and mortality. Unfortunately the early diagnosis of these injuries remains a diagnostic challenge increasing the likelihood of delay. Patients transferred to Level I trauma centers from outlying institutions may be at increased risk of morbidity from hollow viscus injury, as there is an inherent delay associated with transfer. Herein we reviewed our institution's 11-year experience with the diagnosis and treatment of hollow viscus injury caused by blunt mechanism. Forty-one patients met defined criteria of hollow viscus injury. Patients were stratified into two groups: interval to operating room ≤24 hours versus &gt;24 hours. Length of hospital stay, number of ventilator days, and percentage of patients developing acute respiratory distress syndrome were significantly greater in the &gt;24-hour group. Mortality was not significantly different between the groups (26.7% vs 36.4%). Patients transferred from other institutions were more likely to experience complications and operative delay. In conclusion delay in operative intervention (&gt;24 hours) adversely affected outcomes. Early transfer of patients to Level I trauma centers may improve outcomes. A high index of suspicion and the use of multiple diagnostic modalities may lead to earlier operative treatment and improved outcome.

Defining the role of computed tomography in blunt abdominal trauma: use in the hemodynamically stable patient with a depressed level of consciousness.

Controversy exists regarding the use of diagnostic peritoneal lavage (DPL) vs computed tomography (CT) in the evaluation of blunt abdominal trauma. It has been suggested that one role for DPL is to diagnose bowel injuries in hemodynamically stable patients with an unreliable abdominal examination result. Our hypothesis is that CT is specific and sensitive for diagnosing hollow viscus injuries and is therefore an appropriate diagnostic modality in the hemodynamically stable blunt trauma patient with an unreliable abdominal examination result due to a depressed level of consciousness. Retrospective consecutive case review. An urban level II trauma center. The medical records of 1388 consecutive patients admitted between January 1, 1991, and December 31, 2000, were reviewed. Inclusion criteria included blunt trauma patients who were hemodynamically stable (defined as a systolic blood pressure >90 mm Hg) with unreliable abdominal examination results secondary to a depressed level of consciousness (Glasgow Coma Scale score <11). Hollow viscus injury diagnosed by CT and missed diagnosis of hollow viscus injury by CT. Of 1388 patients who met entry criteria, 87 had hollow viscus injuries; CT identified 85 of these injuries. Computed tomography diagnosed intestinal injury with a sensitivity of 97.7%, specificity of 98.5%, and an overall accuracy of 99.4%. At our institution, CT is a reliable and accurate diagnostic modality when used to evaluate hollow viscus injuries in the hemodynamically stable blunt trauma patient with an unreliable abdominal examination result due to a depressed level of consciousness.

The role of oral contrast administration immediately prior to the computed tomographic evaluation of the blunt trauma victim

Background: It is unclear whether the administration of oral contrast followed by immediate computerised tomographic (CT) scanning presents a significant risk of aspiration and whether it is useful in the diagnosis of hollow viscus injury. Objective: Determine the number of intestinal perforations diagnosed by oral contrast enhanced CT scans for blunt trauma and identify those who developed aspiration pneumonitis causally related to oral contrast administration. Methods: We analysed a database of consecutive blunt trauma admissions over a 2-year period. The majority received oral contrast immediately prior to CT scanning. We determined the number of intestinal perforations identified by abdominal CT confirmed at laparatomy and the number of cases of aspiration pneumonia. Results: Nine (1%) of the 1173 CT scans identified enteric perforations. Oral contrast enhanced CT scans demonstrated pneumoperitoneum (3), extraluminal contrast extravasation (2), and the presence of free fluid with small bowel wall thickening (8). In this same cohort, eight (0.7%) cases of aspiration pneumonia were diagnosed within 48 h of admission in patients with a mean GCS of 4.25; only one (0.1%) was temporally related to oral contrast administration. In a prospective study, none of the 65 consecutive patients who received oral contrast had witnessed aspiration. Conclusions: Oral contrast administration given immediately prior to CT scanning does not increase the risk of clinically significant aspiration and assists in the detection of enteric perforation.

Injuries of the gastrointestinal tract from blunt trauma in children: a 12-year experience at a designated pediatric trauma center.

Nonoperative management of solid organ injury from blunt trauma in children has focused concern on potential delays in diagnosis of hollow viscus injury with resultant increases in morbidity, mortality, and cost. This study of a large pediatric trauma database will review the issues of difficulty and/or delay in diagnosis as it relates specifically to definitive treatment and outcome. We surveyed 11,592 consecutive admissions to a designated pediatric trauma center from 1985 to 1997 to identify children with documented injury of the gastrointestinal (GI) tract from blunt trauma. The records were extensively analyzed specifically in regard to mechanism of injury, type and site of injury, time to diagnosis, operative treatment, complications, and final outcome. The 79 children identified, 4 months to 17 years old, included 27 females and 52 males. Mechanism of injury included 15 restrained and 7 unrestrained passengers, 15 pedestrians, 15 child abuse victims, 10 bike handlebar intrusions, 8 discrete blows to the abdomen, 4 bike versus auto, 3 falls, and 2 crush injuries. There were 51 perforations, 6 avulsions, and 22 lesser injuries including contusions. Injury of the small bowel was most common, 44 cases, followed by the duodenum, 18 cases, colon, 17 cases, and stomach, 6 cases. In 45 children, diagnosis was made quickly by a combination of obvious clinical findings, plain x-ray and/or initial computed tomographic findings mandating urgent operative intervention. Diagnosis was delayed beyond 4 hours in 34 children, beyond 24 hours in 17 children and was made by persistent clinical suspicion, aided by delayed computed tomographic findings of bowel wall edema or unexplained fluid. The six deaths were caused by severe head injury. Complications included two delayed abscesses and two cases of intestinal obstruction. All 73 survivors left the hospital with normal bowel function. Injury to the GI tract from blunt trauma in children is uncommon (<1%). The majority of GI tract injuries (60%) are caused by a discrete point of energy transfer such as a seatbelt (19%), a handle bar (13%), or a blow from abuse (19%), or other blows and is unique to this population. Although diagnosis may be difficult and often delayed, this did not result in excessive morbidity or mortality. Safe and effective treatment of GI tract injuries is compatible with nonoperative management of most other injuries associated with blunt abdominal trauma in children, while reducing the risk of nontherapeutic laparotomy.