Diagnostic Peritoneal Lavage Results Research Articles

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma

BackgroundThe diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high. Patients and methodsBlunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR≥1. CT findings, DPL and surgery results, and global outcome were analyzed. ResultsThirty-seven were included in the study (27 males, median age of 30 years (range, 17–69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p=0.02) and small bowel wall abnormalities (p=0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59–100]) and 43% (CI 95% [25–63]). The sensitivity remained 100% (CI 95% [59–100]) when the ratio was ≥4 (n=10 patients), and the specificity reached 90% (CI 95% [73–98]). ConclusionDPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR≥1. Indications for exploratory laparotomy could be restricted to patients with a CCR≥4 to improve the specificity of diagnosis management.

Nonoperative management of anterior thoracoabdominal stab wounds in selected patients

Nowadays, use of selective nonoperative management has decreased the incidence of nontherapeutic laparotomies in patients with anterior thoracoabdominal stab wounds. The safety of selective nonoperative management was investigated in these patients, not requiring emergency laparotomy. Patients referred to the Tabriz Imam Reza Hospital with anterior thoracoabdominal stab wounds were studied from August 2008 to 2010. The hemodynamically unstable patients, those with evidence of peritoneal irritation or with organ evisceration, underwent an emergency laparotomy. For other patients, diagnostic peritoneal lavage (DPL) was used and patients with positive results were operated. Patients with negative DPL results underwent serial physical and laboratory examinations. A total of 204 patients were studied. Sixty-two cases (30.4%) had emergency operations, with 12 (19.4%) cases of nontherapeutic laparotomies. On the basis of DPL results in 142 (69.6%) patients, laparotomy was carried out in another 18 (12.7%) cases with a nontherapeutic result in eight (5.6%) cases. Finally, 124 (60.8%) patients were left for further observation and serial physical and laboratory examinations. Accordingly, five (4%) patients needed delayed laparotomy without any serious complications due to the delayed operation. The length of hospital stay and nontherapeutic laparotomies in our study were lower than mandatory laparotomy management and also, there were no significant complications or mortalities within the 90 days follow-up period. This study showed that the proposed approach of selective nonoperative management in patients with anterior thoracoabdominal stab wounds is safe, feasible, and probably cost-effective.

Diagnostic Peritoneal Lavage Remains a Valuable Adjunct to Modern Imaging Techniques

Continuing improvements in computerized tomography scan technology and widespread acceptance of focused abdominal sonography for trauma (FAST) have prompted the suggestion that diagnostic peritoneal lavage (DPL) is obsolete. This sentiment, coupled with decreasing resident familiarity with DPL, has led to a poor understanding of the modern indications for DPL and no clear guidelines. We hypothesized that, while its indications may have changed, DPL remains essential in the rapid, effective triage of the trauma patient. We queried our Level I trauma center's trauma registry from January 1996 through August 2006 for patients who underwent a DPL as part of their initial evaluation. Specific variables investigated were indications for or results of DPL, performance of a laparotomy in the first 24 hours, and operative findings. Six hundred twenty-seven patients underwent DPL (145 positive, 482 negative). Although the accuracy of DPL for predicting therapeutic laparotomy for all patients was only 77%, in the subset of hemodynamically unstable patients (of which only 46% had a positive FAST), it was 100%. Conversely, only 7% of all patients with negative DPL subsequently had a therapeutic laparotomy, with only 5% in the subset of stab wounds. DPL continues to be a vital tool in the evaluation of the trauma patient. A positive test in the hemodynamically unstable patient with potential multisystem trauma allows for expeditious intervention. A negative test in abdominal stab wounds supports observation and early subsequent discharge. Our current guidelines continue to emphasize the complimentary roles of DPL, FAST, and computerized tomography scan in the trauma bay.

Diagnostic peritoneal lavage in the evaluation of abdominal trauma using the dipstick.

To determine the accuracy and sensitivity of diagnostic peritoneal lavage in the assessment of intra-abdominal injury using the dipstick method. Prospective study, involving the performance of diagnostic peritoneal lavage in the out patient department and surgical wards prior to surgical intervention. Kenyatta National Hospital-General Surgical and Orthopaedic wards and outpatient department. The study was conducted over a duration of six months, starting from January 1995 to July 1995. Ninety six patients with penetrating (68) and blunt (28) abdominal trauma underwent diagnostic peritoneal lavage as evaluation of the severity of abdominal trauma. Dipstick (combur 9 strips) was used to evaluate lavage effluent for red blood cells, white blood cells, protein and bilirubin. Forty three patients had positive diagnostic peritoneal lavage (DPL) results, of which 40 (93%) had positive findings at laparatomy and three (7%) had negative findings at laparatomy. The remaining 53 patients had negative DPL results and were managed conservatively. One patient with a negative DPL result became symptomatic and had a positive laparatomy. Conservatively managed patients were discharged after 24 hours observations without any complications. DPL had an accuracy and sensitivity of 93% and specificity of 98%. Diagnostic peritoneal lavage is a cheap, safe and reliable method for assessment of abdominal trauma. The method is easy to perform by trained junior doctors in the OPD, or as a bedside procedure. Use of this method reduced negative laparotomy rate from 50% to 6.9% and average duration of stay from 6.5 days to 1.9 days. This method is recommended as a basic tool in the assessment of abdominal trauma patients.

Detection of Intra-abdominal Injury Using Diagnostic Peritoneal Lavage after Shotgun Wound to the Abdomen

The utility of diagnostic peritoneal lavage (DPL) as a diagnostic tool specifically for shotgun wound to the abdomen (SGWA) is unknown. This prospective study was undertaken to determine the sensitivity, specificity, and accuracy of DPL for the detection of intra-abdominal injuries following SGWA. DPL was performed on all patients sustaining SGWA who lacked a clear indication for laparotomy. Patients exceeding 10,000 red blood cells (RBC)/mm were taken for exploratory laparotomy. A prospective database was kept with information on wound location, DPL result, findings upon laparotomy and outcome. Thirty-two DPLs were performed at our urban Level I trauma center for SGWA. Of these, 8 patients had a positive DPL. Upon laparotomy, 7 patients were found to have intra-abdominal injuries, 6 of which required surgical intervention. One patient had no peritoneal penetration or intra-abdominal injury. Of the 24 patients that had a negative DPL, 1 subsequently developed indications for laparotomy and was found to have operative injuries. For predicting intra-abdominal injuries DPL has a sensitivity, specificity and accuracy of 87.5%, 95.8% and 93.8%, respectively. For patients presenting with SGWA who do not present with indications for immediate laparotomy, DPL is a reliable indicator of intra-abdominal injury and need for operative intervention.

Experience with over 2500 diagnostic peritoneal lavages

This study was undertaken to confirm the safety and efficacy of diagnostic peritoneal lavage (DPL) for trauma patients. A prospectively maintained database of all DPLs performed in the past 75 months was analyzed. A red blood cell count of 100,000/mm 3 was considered positive for injury in blunt trauma; 10,000/mm 3 was considered positive for peritoneal penetration in penetrating trauma. Information relative to type of injury, DPL result, laparotomy result and complications, was analysed to determine if DPL was more or less suited to any specific indication or type of patient. Over a 75 month period, 2501 DPLs were performed at our urban level I trauma center. The overall sensitivity, specificity and accuracy for the above thresholds were 95, 99 and 98%. The majority (2409, 96%) were performed using percutaneous or “closed” seldinger technique. Ninety-two (4%) were performed using open technique because of pelvic fractures, previous scars and pregnancy. Open DPL was less sensitive than closed DPL in patients who sustained blunt trauma (90 vs 95%) but slightly more sensitive in determining penetration (100 vs 96%). Overall, there were 21 complications (0.8%). There was no difference in complication rate between open and closed DPL. In conclusion, DPL remains a highly accurate, sensitive and specific test with an extremely low complication rate. It can be performed either open or closed with comparable results. We recommend its use in the evaluation of both blunt and penetrating trauma.

Small bowel perforation: is urgent surgery necessary?

Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagnosis is also debatable. The purposes of this study were to evaluate the relationship between treatment delay and outcome of small bowel perforation after blunt abdominal trauma and to determine the best assessment plan for the diagnosis of this injury. One hundred eleven consecutive patients with small bowel perforations caused by blunt abdominal trauma were retrospectively reviewed. The patients were divided into four groups according to the time interval between injury and surgery. Hospital stay, time to resume oral intake, and mortality and morbidity rates were compared between groups. Physical signs, laboratory and computed tomographic findings, and the results of diagnostic peritoneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation. Delay in surgery for more than 24 hours did not significantly increase the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increased significantly when surgery was delayed for more than 24 hours. Abdominal tenderness was a common finding, but it was not specific for bowel perforation. Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage. By using cell count ratio in diagnostic peritoneal lavage and/or increased lavage amylase activity, presence of particulate matter and/or bacteria in the lavage fluid, all patients with intraperitoneal bowel perforation were diagnosed accurately before operation. Small bowel perforation has low mortality and complication rates if it is treated earlier than 24 hours after injury. The principle of "rushing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of treatment for the small bowel perforation should be lower than the limb-threatening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a specially designed positive criterion is applied.

Diagnostic peritoneal lavage in blunt abdominal trauma victims

Diagnostic peritoneal lavage (DPL) is an accepted method for evaluating patients with suspected intra-abdominal injury, especially in those with blunt abdominal trauma for whom early operative intervention may be life-saving. To evaluate this method in blunt abdominal trauma victims, we prospectively studied 2010 patients with blunt abdominal trauma who underwent DPL between 1978 and 1996 in our emergency department (at the regional tertiary university medical centre). The patients were then divided into three groups based on their DPL results. Of the total of 2010 patients, 719 (35.8%) met the criteria for positive DPL, indicating the need for laparotomy; 1213 (60.3%) had a negative DPL; and the remainder (78 patients, 3.9%) had equivocal DPL results. All the patients with positive DPL underwent emergency laparotomies which were therapeutic in 547 (76.1%) and non-therapeutic in 156 (21.7%) who had intra-abdominal haemorrhage. Sixteen patients out of 719 (2.2%) had no organ injuries in explorative laparotomy. When the 2010 cases in this study were evaluated, overall rates of specificity, sensitivity and positive predictive rates were found to be 87.3%, 96.3% and 76.1% respectively; the false positive rate was 23.9%, the false negative rate 1.8% and the negative predictive value 98.2%. Complications related to DPL developed in 31 patients (1.5%) out of the 2010 undergoing DPL. It is evident from the results that DPL is a reliable method. However, the criteria for positive DPL should be re-assessed based on the fact that the method itself had a false positivity rate of 23.9% leading to unnecessary operations.

A method of determining peritoneal penetration in gunshot wounds to the abdomen.

It has previously been shown that 98% of gunshot wounds that penetrate the peritoneal cavity cause injuries that require surgical repair. Many gunshot wounds in the vicinity of the abdomen (GSWA) may actually be tangential and not penetrate the peritoneal cavity at all. Patients with such wounds may not require laparotomy. It is important to determine which patients with a potential tangential GSWA actually have penetration of the peritoneal cavity to minimize negative laparotomies. This study was undertaken to determine the sensitivity, specificity, and accuracy of diagnostic peritoneal lavage (DPL) in the determination of peritoneal penetration for patients who sustain GSWA. DPL was performed for all patients who had sustained a GSWA in whom peritoneal penetration was unclear, i.e., patients whose GSWA appeared to be tangential, thoracoabdominal, or transpelvic and for whom a clear indication for laparotomy (shock, peritonitis, etc.) did not exist. Our threshold for a positive DPL was 10,000 red blood cells (RBC)/mm3. A prospective data base was kept with information on the location of the wound, DPL result, findings at laparotomy, and outcome. During a 4-year period, 429 consecutive DPLs were performed for GSWA at our urban Level I trauma center. One hundred fifty DPLs were positive, with more than 10,000 RBC/mm3. Six of these patients were found to have no peritoneal penetration at laparotomy (false-positive). The remaining 144 patients with positive DPLs were found to have operative injuries (true-positive). Of the 279 patients with DPL counts less than 10,000 RBC/mm3, 2 developed indications for laparotomy and were found to have intraperitoneal injuries (false-negative). The remaining 277 patients had no peritoneal injuries (true-negative). This was demonstrated either by laparotomy done for another indication (n = 7) or by uneventful inpatient observation for 24 hours (n = 270). The sensitivity, specificity, and accuracy of DPL in determining peritoneal penetration in GSWA is therefore 99, 98, and 98%, respectively. For patients who sustain GSWA for whom peritoneal penetration is unclear, DPL is a sensitive, specific, and accurate test to determine the need for laparotomy. It remains our test of choice when confronted with these patients.

Is closed diagnostic peritoneal lavage contraindicated in patients with previous abdominal surgery?

To compare the accuracies and complication rates of diagnostic peritoneal lavage (DPL) in trauma patients with and without previous abdominal surgery. A retrospective review of DPL accuracy and complication rate was performed using all ED trauma patients who underwent DPL during 1993 as identified by the trauma registry. Care was provided at a Level-1 trauma center, a 1,100-bed, central-city teaching hospital with an annual ED census of 84,000. Records were reviewed for a history of previous surgery, DPL results, complications, mechanism of injury, and location of abdominal scars. DPL was performed using the Seldinger technique with a standard Arrow Diagnostic Peritoneal Lavage Kit using an 8-Fr catheter. Rates for patient groups with and without previous abdominal surgery were compared using Fisher's exact test. A "misclassified" DPL was defined as either a positive DPL with negative laparotomy or a negative DPL with subsequent need for laparotomy. "Complications" were defined as iatrogenic injury during the procedure or inability to obtain return of fluid during the lavage. A total of 372 DPLs were performed; 42 in patients with previous surgery and 330 in patients without prior surgery. The groups were similar with respect to proportion with blunt trauma (95% vs 97%), positive DPL (19% vs 19%), misclassified rate (2.4% vs 1.8%), and complication rate (2.4% vs 0.9%); no significant difference was found between groups. The previous abdominal surgeries were appendectomy (n = 20), tubal ligation (n = 5), abdominal hysterectomy (n = 4), cholecystectomy (nonlaparoscopic) (n = 4), pyloric stenosis (n = 1), uterine prolapse (n = 1), undescended testis (n = 1), partial gastrectomy (n = 1), and unknown (n = 5). The analysis had a 90% power of detecting a 10% difference between the 2 groups. The complication rate and accuracy of closed DPL in patients with previous abdominal surgery were similar to those for DPL performed in patients without previous abdominal surgery.

Diagnostic accuracy of peritoneal lavage in patients with pelvic fractures.

To determine the accuracy of diagnostic peritoneal lavage (DPL) for the evaluation of intraabdominal injury in patients with a pelvic fracture as a result of blunt trauma. Retrospective cohort analysis. Level I trauma center in metropolitan Seattle, Wash. Four hundred ninety-seven consecutive patients admitted with pelvic fractures following blunt trauma during a 60-month period. Positive results of DPL, defined by one of the following: an immediate aspiration of more than 10 mL of gross blood; a red blood cell count of more than 0.0001 x 10(12)/L; a white blood cell count greater than 0.0005 x 10(9)/L; an elevated amylase, bilirubin, or creatinine level; or organic particles or bacteria in the effluent returned after installation of 1 L of crystalloid fluid lavaged in the peritoneal cavity. Two hundred eighty-six patients underwent DPL. For 80 patients (28.0%), results of DPL were positive and for 194 patients (67.8%) the results of DPL were negative. For two patients (0.7%), results of DPL were false positive for a sensitivity of 94%. For another two patients (0.7%), the results of DPL were false negative for a specificity of 99%. As a diagnostic modality, DPL has a positive predictive value of 98% and a negative predictive value of 97%. Diagnostic peritoneal lavage is a reliable method for the evaluation of intra-abdominal injury and should remain a standard component in the evaluation of patients following blunt injury with or without pelvic fractures.

Trauma radiology: part I. Computerized tomographic imaging of abdominal trauma.

The value of computerized tomography (CT) scanning for identification of injuries sustained primarily from blunt trauma to the abdomen and pelvis is well established. During the 1980s, numerous articles appeared comparing the value of CT versus diagnostic peritoneal lavage (DPL) as a screening test for intraperitoneal injury. A consensus emerged recognizing the complimentary and different kinds of information provided by each study. CT is indicated in hemodynamically stable patients; to assess the retroperitoneum; after indeterminant DPL results; potentially in patients with positive DPL results by cell count; whenever DPL is contraindicated; in patients with persistent abdominal pain despite a negative DPL; for penetrating flank trauma; for mild abdominal tenderness in alert patients; and arguably for patients with unreliable physical examination. The accuracy of CT is dependent on speed and quality of the scanner, attention to technique to provide optimal oral and intravenous contrast enhancement, and experience of the image interpreter. In general, the accuracy of the CT for detection of solid visceral injuries (including in the liver, the spleen, and the kidneys) and for evaluation of the retroperitoneum is well established. Recent studies indicate that CT also offers important information regarding pancreatic and hollow viscous injuries. Fast scanning with a power-injected intravenous contrast bolus can provide localization of active bleeding sites, with important implications for management by surgery or interventional angiography. We review the CT imaging findings typically observed with a variety of abdominal/pelvic injuries.

Traumatic laceration of the liver limited to the bare area: CT findings in 25 patients.

The capsular extent of traumatic hepatic lacerations may be limited to the bare area of the liver--an area not covered by peritoneal reflection. In these cases, intraperitoneal bleeding may not occur, classic peritoneal findings may be absent, and results of diagnostic peritoneal lavage may be normal. We undertook a study to evaluate the frequency, CT appearance, and significance of injury of the bare area of the liver. We retrospectively reviewed radiologic reports of 1469 hemodynamically stable trauma patients referred for abdominal CT between January 1986 and September 1992 and selected 155 patients whose CT reports indicated hepatic injury. Retrospective review of the abdominal CT scans of these 155 patients confirmed intrahepatic laceration or contusion in all of them. The study involved the 25 (16%) patients in whom the capsular extent of injury was limited to the bare area of the liver. In all cases, CT scans showed simple or complex lacerations involving predominantly or exclusively the posterior segment of the right hepatic lobe, with capsular extent limited to the superomedial hepatic surface. Abnormal retroperitoneal findings were present in all but two cases. Twenty-two (88%) of 25 patients had right-sided retroperitoneal hemorrhage or fluid collections; adrenal hematoma or periadrenal fluid was seen in 12 (48%) patients. Abnormal pericaval fluid collections were present in nine (36%). Only five (20%) patients had free intraperitoneal fluid. Diagnostic peritoneal lavage, performed as a correlative procedure in four patients, revealed intraabdominal hemorrhage in one, equivocal findings in one, and normal findings in two. Patients who had isolated injuries of the bare area of the liver did well clinically and were discharged after an uneventful hospital stay of an average of 3 days (range, 2-7 days). A small percentage of hemodynamically stable patients who have hepatic trauma may have lacerations that primarily involve the bare area and that are not suspected clinically or detected by diagnostic peritoneal lavage. In these patients, CT may be helpful to show the extent of liver injury, identify associated retroperitoneal abnormalities, and provide prognostic information.

Diagnostic Peritoneal Lavage in Evaluation of Acute Abdominal Disease

Diagnostic peritoneal lavage (DPL) is an established procedure in evaluation of trauma victims but is less well established for use in patients suspected of having acute intra-abdominal disease. Twenty-six seriously ill patients at our institution who had DPL for acute intra-abdominal disease form the basis of this report. Use of DPL indicated sepsis in ten patients; in seven of the ten, findings were confirmed at celiotomy or autopsy. Only one of the ten survived without laparotomy or confirmatory necropsy indicating the result of DPL had been false-positive. Sepsis was not indicated by DPL in 16 patients. Fourteen patients appeared to have true-negative results confirmed by operation (three patients), autopsy (four patients), or survival longer than two weeks (seven patients). Complications occurred in one patient whose DPL showed sepsis. Two patients with negative results of DPL died within two weeks of examination without confirmatory operation or autopsy and could not be evaluated. We therefore, consider the overall diagnostic accuracy in our patient group to be 95%. We recommend the use of DPL in patients suspected of an acute intra-abdominal disease process who are unable to undergo other evaluation for reasons such as critical illness.