Assessment of abdominal trauma in adults

Patient must be haemodynamically stable. Most sensitive study to diagnose splenic injuries.[36]Deunk J, Dekker HM, Brink M, et al. The value of indicated computed tomography scan of the chest and abdomen in addition to the conventional radiologic work-up for blunt trauma patients. J Trauma. 2007 Oct;63(4):757-63. http://www.ncbi.nlm.nih.gov/pubmed/18090002?tool=bestpractice.com

Directs treatment based on the seriousness of the injury.[36]Deunk J, Dekker HM, Brink M, et al. The value of indicated computed tomography scan of the chest and abdomen in addition to the conventional radiologic work-up for blunt trauma patients. J Trauma. 2007 Oct;63(4):757-63. http://www.ncbi.nlm.nih.gov/pubmed/18090002?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: CT scan showing splenic lacerationCollection of the MetroHealth Medical Center [Citation ends].

Haemoglobin and haematocrit levels drawn shortly after a haemorrhagic event do not accurately reflect the amount of blood loss.

A focused assessment with sonography in trauma (FAST) examination is useful to quickly diagnose intra-abdominal haemorrhage.[23]Soyuncu S, Cete Y, Bozan H, et al. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal hemorrhage in blunt abdominal trauma. Injury. 2007 May;38(5):564-9. http://www.ncbi.nlm.nih.gov/pubmed/17472792?tool=bestpractice.com [24]Quinn AC, Sinert R. What is the utility of the Focused Assessment with Sonography in Trauma (FAST) exam in penetrating torso trauma? Injury. 2011 May;42(5):482-7. http://www.ncbi.nlm.nih.gov/pubmed/20701908?tool=bestpractice.com The FAST examination uses a bedside ultrasound to provide images of the right upper quadrant, left upper quadrant, and pelvis to assess for intra-abdominal haemorrhage. In 2006, a study from the UK found the FAST examination to have a sensitivity of 78% and a specificity of 99% in the detection of intra-abdominal haemorrhage.[38]Brenchley J, Walker A, Sloan JP, et al. Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emerg Med J. 2006 Jun;23(6):446-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564340 http://www.ncbi.nlm.nih.gov/pubmed/16714505?tool=bestpractice.com

If a FAST examination is unavailable or unreliable, a DPL may be performed to assess for intraperitoneal bleeding.[26]Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med. 2009 Mar 8;17:13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2663535 http://www.ncbi.nlm.nih.gov/pubmed/19267941?tool=bestpractice.com

Patient must be haemodynamically stable. Most sensitive study to diagnose hepatic injuries.[36]Deunk J, Dekker HM, Brink M, et al. The value of indicated computed tomography scan of the chest and abdomen in addition to the conventional radiologic work-up for blunt trauma patients. J Trauma. 2007 Oct;63(4):757-63. http://www.ncbi.nlm.nih.gov/pubmed/18090002?tool=bestpractice.com

Most haemodynamically stable patients with hepatic injuries can be managed non-operatively.[12]Powell BS, Magnotti LJ, Schroeppel TJ, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May;39(5):530-4. http://www.ncbi.nlm.nih.gov/pubmed/18336818?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: CT scan showing hepatic lacerationCollection of the MetroHealth Medical Center [Citation ends].

Haemoglobin and haematocrit levels drawn shortly after a haemorrhagic event do not accurately reflect the amount of blood loss.

A focused assessment with sonography in trauma (FAST) examination is useful to quickly diagnose intra-abdominal haemorrhage.[23]Soyuncu S, Cete Y, Bozan H, et al. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal hemorrhage in blunt abdominal trauma. Injury. 2007 May;38(5):564-9. http://www.ncbi.nlm.nih.gov/pubmed/17472792?tool=bestpractice.com [24]Quinn AC, Sinert R. What is the utility of the Focused Assessment with Sonography in Trauma (FAST) exam in penetrating torso trauma? Injury. 2011 May;42(5):482-7. http://www.ncbi.nlm.nih.gov/pubmed/20701908?tool=bestpractice.com The FAST examination uses a bedside ultrasound to provide images of the right upper quadrant, left upper quadrant, and pelvis to assess for intra-abdominal haemorrhage. In 2006, a study from the UK found the FAST examination to have a sensitivity of 78% and a specificity of 99% in the detection of intra-abdominal haemorrhage.[38]Brenchley J, Walker A, Sloan JP, et al. Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emerg Med J. 2006 Jun;23(6):446-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564340 http://www.ncbi.nlm.nih.gov/pubmed/16714505?tool=bestpractice.com

If a FAST examination is unavailable or unreliable, a DPL may be performed to assess for intraperitoneal bleeding.[26]Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med. 2009 Mar 8;17:13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2663535 http://www.ncbi.nlm.nih.gov/pubmed/19267941?tool=bestpractice.com

If haematuria is present (gross or microscopic) the nature of the injury must be determined. Lacerations to the kidney and avulsed blood vessels can bleed extensively into the retroperitoneal space.

Most blunt renal injuries can be managed non-operatively.

While free air may be diagnostic for hollow viscus injury, it is generally not seen.

In gunshot wounds (GSWs) to the abdomen, plain films are useful to predict the trajectory of the bullet.

While free air may be diagnostic for hollow viscus injury, it is generally not seen.

In GSWs to the abdomen, plain films are useful to predict the trajectory of the bullet.

While CT scans are helpful for diagnosis of small bowel injury, the findings are often subtle, especially for the radiologist or clinician unaccustomed to evaluating blunt trauma. High false-negative rates may occur with CT.

Diagnostic peritoneal lavage can be helpful in evaluating patients with equivocal CT findings.[42]Sherck J, Shatney C, Sensaki K, et al. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994 Dec;168(6):670-5. http://www.ncbi.nlm.nih.gov/pubmed/7978016?tool=bestpractice.com

DPL can be helpful in evaluating patients with equivocal CT findings.[42]Sherck J, Shatney C, Sensaki K, et al. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994 Dec;168(6):670-5. http://www.ncbi.nlm.nih.gov/pubmed/7978016?tool=bestpractice.com

If the aspirate is found to contain 10 mL of gross blood or bile, an exploratory laparotomy is indicated.

In the absence of gross blood or bile, DPL requires 1 litre of fluid to be infused into the peritoneum and then drained. The effluent should be sent to the laboratory and evaluated.

Highly sensitive study but has a low specificity.[26]Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med. 2009 Mar 8;17:13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2663535 http://www.ncbi.nlm.nih.gov/pubmed/19267941?tool=bestpractice.com

Small injuries are hard to see on CT.

Early normal serum lipase and/or amylase does not exclude major pancreatic trauma. Persistent elevation of amylase and lipase is suggestive of pancreatic injury. Serum lipase is more sensitive and specific for pancreatic injury than serum amylase; monitoring both together increases accuracy.[8]Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:56. https://www.doi.org/10.1186/s13017-019-0278-6 http://www.ncbi.nlm.nih.gov/pubmed/31867050?tool=bestpractice.com

May visualise minor injuries better than CT; recommended to definitively exclude pancreatic parenchymal and ductal injuries.[8]Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:56. https://www.doi.org/10.1186/s13017-019-0278-6 http://www.ncbi.nlm.nih.gov/pubmed/31867050?tool=bestpractice.com

CXR is often an equivocal study for diaphragmatic injury.

Placement of a nasogastric tube and acquiring a follow-up CXR is helpful for identification of the stomach herniating into the chest.

CT is a fairly sensitive study for blunt diaphragm injuries, but not for penetrating injuries.

CT is a fairly sensitive study for blunt diaphragm injuries, but not for penetrating injuries.

Diagnostic test of choice for penetrating injuries.

Especially useful in patients with thoraco-abdominal injuries where there is a high suspicion of diaphragmatic injury.[12]Powell BS, Magnotti LJ, Schroeppel TJ, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May;39(5):530-4. http://www.ncbi.nlm.nih.gov/pubmed/18336818?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Laparoscopic repair of diaphragmCollection of the MetroHealth Medical Center [Citation ends].[Figure caption and citation for the preceding image starts]: Laparoscopic view of diaphragm injuryCollection of the MetroHealth Medical Center [Citation ends].

While free air may be diagnostic for hollow viscous injury, it is generally not seen.

In gunshot wounds (GSWs) to the abdomen, plain films are useful to predict the trajectory of the bullet.

While free air may be diagnostic for hollow viscous injury, it is generally not seen.

In GSWs to the abdomen, plain films are useful to predict the trajectory of the bullet.

While free air may be diagnostic for hollow viscous injury, it is generally not seen.

In gunshot wounds (GSWs) to the abdomen, plain films are useful to predict the trajectory of the bullet.

While free air may be diagnostic for hollow viscous injury, it is generally not seen.

In GSWs to the abdomen, plain films are useful to predict the trajectory of the bullet.

In a stable patient, CT may assist in the diagnosis of a colorectal injury.

Blunt injuries are usually identified by the presence of free air or mesenteric haematoma.

Select penetrating injuries to the left flank may benefit from a triple contrast CT which includes rectal contrast.

Identification of contrast extravasation is diagnostic of an injury, and indicates the need for operative intervention.

High false-negative rate for diagnosis of mesenteric injury, leading to delayed diagnosis.[42]Sherck J, Shatney C, Sensaki K, et al. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994 Dec;168(6):670-5. http://www.ncbi.nlm.nih.gov/pubmed/7978016?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: CT scan showing intraperitoneal fluidCollection of the MetroHealth Medical Center [Citation ends].

If the aspirate is found to contain 10 mL of gross blood or bile, an exploratory laparotomy is indicated.

In the absence of gross blood or bile, DPL requires 1 litre of fluid to be infused into the peritoneum and then drained. The effluent should be sent to the laboratory and evaluated.

Highly sensitive study but has a low specificity.[26]Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med. 2009 Mar 8;17:13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2663535 http://www.ncbi.nlm.nih.gov/pubmed/19267941?tool=bestpractice.com

Contrast is injected directly into the bladder. A CT scan is then taken with a full bladder.[43]American College of Radiology. ACR Appropriateness Criteria® . Penetrating trauma – lower abdomen and pelvis. 2019 [internet publication]. https://acsearch.acr.org/docs/69376/Narrative

A bladder injury is confirmed if contrast is seen to extravasate outside of the bladder (i.e., visualisation of contrast in the peritoneal cavity or retroperitoneal space).[44]European Association of Urology. EAU guidelines on urological trauma. 2024 [internet publication]. https://uroweb.org/guidelines/urological-trauma

Urea and creatinine may be elevated with intraperitoneal bladder rupture due to reabsorption of urea nitrogen and creatinine.​[45]Sung CW, Chang CC, Chen SY, et al. Spontaneous rupture of urinary bladder diverticulum with pseudo-acute renal failure. Intern Emerg Med. 2018 Jun;13(4):619-22. https://link.springer.com/article/10.1007/s11739-018-1796-z http://www.ncbi.nlm.nih.gov/pubmed/29383475?tool=bestpractice.com [46]Matsumura M, Ando N, Kumabe A, et al. Pseudo-renal failure: bladder rupture with urinary ascites. BMJ Case Rep. 2015 Nov 20;2015:bcr2015212671. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4680254 http://www.ncbi.nlm.nih.gov/pubmed/26590189?tool=bestpractice.com

Intraperitoneal bladder rupture requires operative repair, while extraperitoneal rupture requires drainage with a Foley's catheter.

Should be sent due to the anticipation of blood transfusions.

Indicated in unstable patients with blunt abdominal trauma.

Indicated in stable patients with blunt abdominal trauma.