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Perforating injuries of the small bowel from blunt abdominal trauma
ORIGINAL CONTRIBUTION abdominal trauma, blunt, small bowel injury; bowel, small, perforating injury; trauma, abdominal, blunt
Perforating Injuries of the Small Bowel From Blunt Abdominal Trauma O u r experience with perforating injuries of the small bowel from bhmt abdominal trauma over a nine-year period has been analyzed. TWelve patients had full-thickness perforation of the bowel wall. In nine (75%), the ddagnosis of a surgical lesion of the abdomen was made by the combination of physical examination and the results of peritoneal lavage. Three patients (25%) had equivocal physical findings and a negative initial peritoneal lavage, and the diagnosis of a surgical lesion of the abdomen was not made at the time of admission. Two of these developed clinical evidence of peritonitis within 12 hours of admission, and the specific diagnosis was made at operation. Serial peritoneal lavage with both RBC and WBC counts was successful in confirming the diagnosis of a surgical lesion in one. Peritoneal lavage WBC counts were not performed on the other two patients. In one of these two, the diagnosis was missed for five days. Septic complications and wound dehiscence were common, occurring in 50% of the entire group. The u s e of serial peritoneal lavage with both RBC and WBC counts may assist in making the diagnosis in this group of patients. Our data indicate, but do not prove, that the majority of those who sustain this injury, but whose level of consciousness remains clear (or clears progressively as a result of drug or alcohol metabolism) will develop clinical evidence of peritonitis within 12 hours of injury. This emphasizes the importance of serial abdominal examinations even after a negative peritoneal ]avage. /Phillips TF, Brotman S, Cleveland S, Cowley RA: Perforating injuries of the small bowel from blunt abdominal trauma. Ann Emerg Med 12:75-79, February 1983.]
Thomas F. Phillips, MD* Sheldon Brotman, MD* Baltimore, Maryland Samuel Cleveland, DO t Akron, Ohio R Adams Cowley, MD* Baltimore, Maryland From the Maryland Institute of Emergency Medical Services Systems, Baltimore;* and Akron General Hospital, Akron, Ohio/ Presented at the Scientific Assembly of the Ohio Chapter of the American College of Emergency Physicians in Akron, Ohio, May 1981. Submitted September 1981; revision received July I982. Address for reprints: Thomas F Phillips, MD, Department of Surgery, Wayne State University, 4S-13 Detroit Receiving Hospital, 4201 St Antoine, Detroit, Michigan 48201.
INTRODUCTION High-speed automobile accidents with severe blunt trauma to the trunk may result in complex combinations of injuries. Full-thickness small bowel perforation is an u n c o m m o n result of blunt abdominal trauma, occurring in only 4% of the patients explored for abdominal trauma at our institution {E. Cox, Department of Surgery, MIEMSS, 1981, personal communication). Over a brief period during 1980-1981, we were confronted with several patients with this lesion. On the basis of this limited experience we became impressed with several important aspects of this injury. At times it was difficult to diagnose because of the presence of other injuries. In at least three cases the injury remained occult at the time the patient was first evaluated. In these three, peritoneal lavage failed to detect this injury. Finally, even when diagnosed and treated appropriately, the injury seemed to be associated with a surprising degree of morbidity and some mortality. For this reason we elected to review the experience of our institution with this lesion over a nine-year period.
MATERIALS A N D METHODS Hospital records from October 1972 to January 1981 were reviewed. A total of 79 patients had some form of small intestinal injury, including injuries to the mesentery. However, only 12 of these were documented full-thickness intestinal injuries with spillage of intraluminal contents following blunt abdominal trauma. These 12 cases were analyzed in more detail, and form the basis for this report. 12~2 February 1983
Annals of Emergency Medicine
75/21
SMALL BOWEL PERFORATION Phillips et al
Figure. Field triage criteria for trauma center transfer. The group consisted of four women and eight men between the ages of 16 years and 64 years. Reliable data were not available on the precise mechanism of injury in each case. The available information has been excluded because of the subjectivity and lack of verification of reports from the accident scene. All patients were victims of blunt trauma sustained in motor vehicle accidents, and all had met the field triage criteria (Figure) for helicopter transport to our institution. The elapsed time from injury to arrival did not exceed one hour. Peritoneal lavage is used liberally in our institution for the diagnosis of intraperitoneal hemorrhage following blunt trauma. Our technique and our criteria (Table 1) for interpreting the results of peritoneal lavage have been previously published. 1'~ Patients who have positive findings on peritoneal lavage are routinely explored. Patients with negative results are followed clinically based on the findings of serial examinations. Patients whose lavage cell counts are in the indeterminate range are usually managed by leaving the peritoneal lavage catheter in place and repeating the lavage two to four hours later by infusing another 1,000 cc of saline (20 cc/kg in children) through the same catheter. Positive results on this second lavage are d e t e r m i n e d by using the same criteria as on the first, and result in laparotomy. Negative results on the second lavage are interpreted as truly negative, and the patients are followed clinically. When the result of the second lavage also falls in the indeterminate range, the surgeon has the option of performing a third lavage using the same technique and criteria after another two to four hours, or acting on the trend of the cell counts. The Procedure in this situation is not uniform. However, a patient with an initial cell count of 60,000 RBC/mm 3 that increases to 85,000 on a second lavage is likely to be explored surgically. If the initial cell count were 80,000 R B C / m m 3 and fell to 60,000 on second lavage, the patient is likely to be observed clinically. If two serial p e r i t o n e a l lavages b o t h had cell counts of 75,000 RBC/mm 3, the patient likely would be subjected to a third peritoneal lavage.
A. Trauma combination: head, chest, abdomen, extremity• B. Crush-blunt trauma: chest, abdomen, pelvis• C. Penetrating chest wound: gunshot wound, stab, impaled objects. D. Injury with severe hemorrhage: systolic blood pressure < 80. E. Paralysis or vascular impairment: one or more extremities• F. Unconscious trauma patient: loss of consciousness > 5 minutes. G. Head trauma: pupils unequal. H. Penetrating wounds of the abdomen• I. Patient extricated from accident wreckage after 30 minutes. J. Amputation of finger, hand, extremity.
TABLE 1. Criteria for interpreting results of peritoneal Iavage Positive:
Lavage fluid exits Foley catheter or chest tube. Return of > 10 cc of frank blood upon aspiration of dialysis catheter. > 100,000 RBCs per mm 3. > 500 WBCs per mm 3.
Negative:
< 50,000 RBCs per mm 3, < 100 WBCs per mm3•
Indeterminate:
50,000-100,000 RBCs per mm 3. 100-500 WBCs per mm 3.
The d e t e r m i n a t i o n s of amylase, bilimbin, and bacterial counts are not routinely performed on peritoneal lavage fluid in our institution, nor is the serum amylase. Charts were analyzed for the clinical status of the patients at the time of admission, the results of peritoneal lavage, the presence of associated injuries, mortality, and complications. Particular attention was focused on the ability to make the diagnosis at the time of admission, using the combination of physical examination and peritoneal lavage.
all eight. One patient was in profound shock on admission and had a visibly distending abdomen. She was explored i m m e d i a t e l y on the basis of these findings alone. Three of the patients in this group had associated intraperitoneal visceral injuries that contributed to their positive lavage findings (Table 2). Five p a t i e n t s had major orthopedic injuries. Group II consisted of three patient s in w h o m the diagnosis of intra-abdominal injury requiring laparotomy was not made at the time of initial assessment.
RESULTS
Case Number One
All patients fell into one of two clinical categories. Group I consisted of nine patients with severe blunt multiple trauma. In this group t h e diagnosis of small bowel p e r f o r a t i o n was n o t m a d e preoperatively in any patient because the findings were not specific fo r this injury. However, all these patients were either in shock on admission (six patients) or had sustained serious head injury. Peritoneal lavage was performed in eight (89%), and the initial lavage was unequivocally positive in
This patient underwent peritoneal la-cage because his s e n s o r i u m was altered by alcohol intoxication at the t i m e of the motor vehicle accident. He was n o t hypotensive, b u t bowel sounds were absent. Initial lavage findings included an RBC count of 80,000/mm 3, and therefore the lavage was repeated at four hours according to the standard procedure. The second p e r i t o n e a l lavage RBC count was 60,000. The patient was followed clinica'lly, and within six hours of his second lavage (12 hours after injury)
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Morbidity and Mortality TABLE 2. Associated injuries by group Group I Serious head injuries Major orthopedic injuries Other intra-abdominal injuries Spleen and liver ColonShock on admission Isolated small bowel injury Multiple small bowel perforations
Group II 1
Total number of patients
he developed clinical peritonitis with localized abdominal tenderness and rebound tenderness. Exploration was performed at this time, and a small bowel perforation was discovered and repaired.
Case Number Two This patient was a 23-year-old man who was in an agitated condition when first evaluated following blunt trauma to the trunk in a motor vehicle accident. His mental status appeared to be the result of an acute drug intoxication. His blood pressure was 110/80 m m Hg, and his pulse was 90 beats per minute. There was no external evidence of abdominal trauma and bowel sounds were present, but the findings of abdominal palpation were uninterpretable because the patient was agitated and u n a b l e to cooperate with the examination. Peritoneal lavage was performed. The RBC count was only 7,100/ram 3, but the WBC was equivocal at 345/mm 3. In four hours peritoneal lavage was repeated with an RBC count of 22,400/ m m 3, but the WBC count was now grossly elevated at 8,400/mm 3. Physical examination at this time revealed localized abdominal tenderness and clinical signs of early peritonitis. Exploration was performed on the basis of both the lavage results and the change in clinical findings. An isolated small intestinal perforation was found and repaired. Ornental adhesions at the site of the injury had minimized intestinal spillage. Recovery was uncomplicated.
Case Number Three The most distressing of our indeterminate cases was that of a 20-year-old woman who sustained a pelvic fracture in a high-speed collision. Peritoneal lavage was performed. Initial 12:2 February 1983
results revealed RBCs of 15,000/mm3; WBCs were not recorded. For reasons that remain obscure, the lavage was repeated twice in spite of the initial negative result. Questionable physical findings appear to have motivated the surgical team to doubt the results of the initial lavage. The second RBC count was 45,000/ram 3, and the third, 96,000. These rising RBC counts were attributed to intraperitoneal leakage of cells from the retroperitoneal hematoma caused by the patient's pelvic fracture, a phenomenon which is known to occur. 3 Five days post injury the patient developed clinical evidence of intra-abdominal sepsis including fever, leukocytosis, and abdominal tenderness. Surgical exploration revealed a subhepatic abscess resulting from a full-thickness small bowel perforation. Omental adhesions had sealed the perforation and limited free peritoneal soilage. The subhepatic abscess apparently resulted from contamination occurring in the period immediately following the initial injury.
Associated Injuries Of the nine patients in Group I, two had isolated small bowel injuries, w i t h bleeding from the mesentery being responsible for the positive lavage. In the remaining seven, there were five major orthopedic injuries, three severe head injuries, and four associated visceral injuries (two splenic ruptures, both of which had associated minor liver lacerations, and two injuries to the colon) (Table 2). In Group II (the occult visceral injury group), one of the three patients had a major orthopedic injury (a fractured pelvis) and two had isolated small bowel perforation. Four of the total of 12 patients had multiple perforations, and all of these fell into Group I. Annals of Emergency Medicine
Two patients in the series died, for an overall mortality of 17%. One, who was admitted in profound shock, died within 48 hours of admission from multiple organ failure that included acute anuric renal failure and sepsis. The other was discharged ten days following admission after an apparently uncomplicated hospital course. He was readmitted in septic shock with a blood pressure of 90/50 m m Hg, 48 hours after discharge. At exploration he was found to have ten feet of gangrenous bowel in the area of the small intestinal anastomosis. He died ten days postoperatively of multiple organ failure. Six patients in this series (50%) developed clinical sepsis (Table 3). This included one patient who developed a subhepatic abscess and wound dehiscence five days after injury, one patient who also had a colon injury and developed a pelvic abscess and wound dehiscence, one patient whose occult small bowel injury was not diagnosed until she developed a subhepatic abscess and clinical signs of intra-abdominal sepsis five days after injury, and one patient who developed a subcutaneous wound infection. Two patients experienced clinical septic episodes and were successfully treated with antibiotics and supportive measures. A definite source of infection could not be identified in either patient. Neither of the two patients whose diagnosis was delayed for four to six hours awaiting clinical evidence of localized peritonitis or a positive peritoneal lavage WBC count experienced septic complications. Neither of these two patients was ever in shock. Hospital stays ranged from six to 43 days. The two patients with the longest hospital stays included one patient with multiple perforations and the one whose diagnosis was delayed for five days. Both required exploration for intraperitoneal abscess.
DISCUSSION From this review several important aspects of blunt small bowel injury become apparent. Although uncommon, 4'5 this injury can be responsible for a surprising degree of morbidity. In the majority of patients the diagnosis will be made at operation, based on clear clinical evidence of hemorrhagic shock of abdominal origin or as the result of an initial positive peritoneal lavage performed at the time of ad77/23
SMALL BOWEL PERFORATION Phillips et al
mission. In a minority of patients early diagnosis of this injury may prove difficult. Physical findings at the time of initial examination may be limited, and initial peritoneal lavage results may be negative. The presence of head injury or drug or alcohol intoxication m a y further obscure the diagnosis. Finally, the presence of other easily diagnosed injuries, s u c h as C N S or orthopedic injuries, may detract attention from the abdomen. The three theoretical mechanisms of p e r f o r a t i n g s m a l l b o w e l injury r e s u l t i n g f r o m b l u n t t r a u m a are crushing, shearing, and bursting. 6-9 A crushing injury results from direct impact of the small bowel against the anterior portion of the vertebral column. A shearing injury occurs when the inertial effects arising from highspeed impact exceed the equalizing force of the small bowel at the attachment points, ie, the ligament of Treitz and the cecum. A bursting injury can result from blunt trauma in which the force of impact is transmitted through the abdominal wall, resulting in disruption secondary to a rapid increase in intraluminal pressure. Peritoneal lavage has been the single most reliable diagnostic tool used at our institution for the evaluation of blunt abdominal trauma. The accuracy rate of peritoneal lavage for all our patients with abdominal trauma has been 97.8%. 1° However, in this series of patients with small bowel injuries the accuracy was only 75%, due to a false-negative rate of 25%. Engrav et a111 reported missing 16% of small bowel injuries using peritoneal lavage. Although not statistically significant, our experience indicates that most conscious patients with this injury will probably develop such clinical evidence of peritonitis as.localized abdominal tenderness, localized rebound tenderness, and loss of bowel sounds within 12 hours of injury. Serial abdominal examinations by the same examiner, and consideration of repeat peritoneal lavage using both red and white blood cell counts are important ways of pursuing the diagnosis in the group of patients with equivocal findings on admission physical examination and indeterminate results on initial peritoneal lavage. New abdominal findings must be interpreted seriously, and exploratien m u s t be u n d e r t a k e n in q u e s t i o n a b l e cases. Nonetheless, this injury may remain occult, as demonstrated by one patient in our series and another reported in 24/78
TABLE 3. Septic and w o u n d complications Total Subhepatic abscess Wound dehiscence Pelvic abscess Subcutaneous wound infection Occult sepsis responsive to antibiotics Total number of patients with septic complications Total number of patients
the literature in w h o m the diagnosis was delayed 35 days. 12 The diagnosis of small bowel perforation can be missed easily in the patient whose sensorium is significantly altered by head trauma or intoxicants. In these patients the use of serial peritoneal lavage utilizing both red and white blood cell counts 13'15 may provide the only clue to the presence of a significant intraperitoneal injury. In this setting, an elevated and rising serum amylase on serial determinations may contribute to the diagnosis. T h e routine use of either serum, 16'17 or peritoneal lavage fluid 13 amylase determinations is not cost effective and is likely to be misleading.13,16,17 Septic complications were promin e n t in our series of patients. Alt h o u g h it r e m a i n s speculative, we believe that it is the combination of intraperitoneal soilage and the nonspecific i m m u n o l o g i c defect associated with shock that are responsible for the high incidence of sepsis in our series of patients. The picture is somewhat clouded by the fact that one of our patients who developed intra-abdominal sepsis also sustained a colon injury, and another patient's injury was not diagnosed and treated until sepsis supervened five days later. Two of our patients who had delays in diagnosis of four to six hours, but who were not in shock at any time, experienced u n c o m p l i c a t e d postoperative courses. We have identified only three patients in w h o m this diagnosis was missed by peritoneal lavage:during a t i m e period in w h i c h nearly 3,000 peritoneal lavages were performed for blunt abdominal trauma. Thus these data do not diminish the role of peritoneal lavage in blunt trauma. However, because peritoneal lavage is known Annals of Emergency Medicine
Group I
Group II
2 2 1 1 2
I 2 1 1 2
1
6
5
1
12
9
3
to have an inaccuracy rate of from 3% to 5%, 1'~'1°'1s-~° and 25% of our patients had a false-negative initial lavage, small bowel perforation may be among the injuries that can be present even in the presence of negative study. REFERENCES 1. Du Priest RW, Khaneja SC, Rodriguez A, et al: Technique for open diagnostic peritoneal lavage. Surg Gynecol Obstet 147:241-243, 1978. 2. Soderstrom CA, Du Priest RW, Cowley RA: Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstet 151:513-518, i980. 3. Hubbard SG, Bivins BA, Sachatello CR, et al: Diagnostic errors with peritoneal lavage in patients with pelvic fractures. Arch Surg 114:844-846, 1979. 4. Shuck JM, Lowe RJ: Intestinal disruption due to blunt abdominal trauma. Am J Surg 136:668-673, 1978. 5. Cerise EJ, Scully JH: Blunt trauma to the small intestine. J Trauma 10:46-50, 1970. 6. Sube J, Ziperman HH, McIver WJ: Seat belt trauma to the abdomen. Am J Surg 113:346-350, 1967. 7. Snyder CJ: Bowel injuries from automobile seat belts. Am J Surg 123:312-316, 1972. 8. Geoghegam T, Brush BE: The mechanism of intestinal perforation from nonpenetrating abdominal trauma. Arch Surg 73:455-464, 1956. 9. Williams RD, Sargent FT: The mechanism of intestinal injury in trauma. J Trauma 3:288-293, 1963. 10. Du Priest RW, Rodriguez A, Khaneja SC, et al: Open diagnostic peritoneal lavage in blunt trauma victims. Surg Gynechl Obstet 148:890-894, 1979. . 1i. Engrav LM, Benjamin CI, Strate RG, et al: Diagnostic peritoneal lavage in blunt abdominaI trauma. J Trauma 15:854-859, 1975. 12'. Flaisham HA, Griffith GL, Bivins BA: Delayed perforation of the small bowel fol12:2 February 1983
lowing blunt abdominal trauma. ] Ky Med Assoc 77:294-296, 1979. t3. Alyono D, Perry JF: Value of quantitative cell count and amylase activity of peritoneal lavage fluid. J Trauma 21:345-348, 1981. 14. Brotman S, Phillips TF, Cowley RA: The importance of serial white blood cell counts in diagnostic peritoneal dialysates in blunt trauma. Md State Med J 30:2, 1981.
15. Root H, Keizer PJ, Perry JF: The clinical and experimental aspects of peritoneal response to injury. Arch Surg 95:631, 1967. 16. Moretz JA, Campbell DP, Parker DE, et al: Significance of serum amylase level in evaluating pancreatic trauma. Am J Surg 130:739-741, 1975. 17. Olsen WR: The serum amylase in blunt abdominal trauma. J Trauma 13:200204, 1973. 18. Perry JE, Strate RG: Diagnostic peri-
ABEM
Notice
toneal lavage in blunt abdominal trauma: Indications and results. Surgery 6:898-901, 1972. 19. Hunt KE, Garrison RN, Fry DE: Perforating injuries of the gastrointestinal tract following blunt abdominal trauma. Am Surgeon 45:101-104, 1980. 20. Ahmad W, Polk HC: Blunt abdominal trauma, a prospective study with selective peritoneal lavage. Arch Surg I1:489-492, 1976.
~
On June 30, 1988, the practice option will t e r m i n a t e for those physicians wishing to m e e t the credential requirem e n t s of the A m e r i c a n Board of Emergency Medicine's certification examination. Practice, teaching, or CME a c c u m u l a t e d after the above date m a y not be used to satisfy the practice requirements. Q u e s t i o n s should be directed to ABEM, 1305 A b b o t t Road, Suite 101, East Lansing, MI 48823; 517/332-4800.
12:2 February 1983
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Perforating Injuries of the Small Bowel From Blunt Abdominal Trauma O u r experience with perforating injuries of the small bowel from bhmt abdominal trauma over a nine-year period has been analyzed. TWelve patients had full-thickness perforation of the bowel wall. In nine (75%), the ddagnosis of a surgical lesion of the abdomen was made by the combination of physical examination and the results of peritoneal lavage. Three patients (25%) had equivocal physical findings and a negative initial peritoneal lavage, and the diagnosis of a surgical lesion of the abdomen was not made at the time of admission. Two of these developed clinical evidence of peritonitis within 12 hours of admission, and the specific diagnosis was made at operation. Serial peritoneal lavage with both RBC and WBC counts was successful in confirming the diagnosis of a surgical lesion in one. Peritoneal lavage WBC counts were not performed on the other two patients. In one of these two, the diagnosis was missed for five days. Septic complications and wound dehiscence were common, occurring in 50% of the entire group. The u s e of serial peritoneal lavage with both RBC and WBC counts may assist in making the diagnosis in this group of patients. Our data indicate, but do not prove, that the majority of those who sustain this injury, but whose level of consciousness remains clear (or clears progressively as a result of drug or alcohol metabolism) will develop clinical evidence of peritonitis within 12 hours of injury. This emphasizes the importance of serial abdominal examinations even after a negative peritoneal ]avage. /Phillips TF, Brotman S, Cleveland S, Cowley RA: Perforating injuries of the small bowel from blunt abdominal trauma. Ann Emerg Med 12:75-79, February 1983.]
Thomas F. Phillips, MD* Sheldon Brotman, MD* Baltimore, Maryland Samuel Cleveland, DO t Akron, Ohio R Adams Cowley, MD* Baltimore, Maryland From the Maryland Institute of Emergency Medical Services Systems, Baltimore;* and Akron General Hospital, Akron, Ohio/ Presented at the Scientific Assembly of the Ohio Chapter of the American College of Emergency Physicians in Akron, Ohio, May 1981. Submitted September 1981; revision received July I982. Address for reprints: Thomas F Phillips, MD, Department of Surgery, Wayne State University, 4S-13 Detroit Receiving Hospital, 4201 St Antoine, Detroit, Michigan 48201.
INTRODUCTION High-speed automobile accidents with severe blunt trauma to the trunk may result in complex combinations of injuries. Full-thickness small bowel perforation is an u n c o m m o n result of blunt abdominal trauma, occurring in only 4% of the patients explored for abdominal trauma at our institution {E. Cox, Department of Surgery, MIEMSS, 1981, personal communication). Over a brief period during 1980-1981, we were confronted with several patients with this lesion. On the basis of this limited experience we became impressed with several important aspects of this injury. At times it was difficult to diagnose because of the presence of other injuries. In at least three cases the injury remained occult at the time the patient was first evaluated. In these three, peritoneal lavage failed to detect this injury. Finally, even when diagnosed and treated appropriately, the injury seemed to be associated with a surprising degree of morbidity and some mortality. For this reason we elected to review the experience of our institution with this lesion over a nine-year period.
MATERIALS A N D METHODS Hospital records from October 1972 to January 1981 were reviewed. A total of 79 patients had some form of small intestinal injury, including injuries to the mesentery. However, only 12 of these were documented full-thickness intestinal injuries with spillage of intraluminal contents following blunt abdominal trauma. These 12 cases were analyzed in more detail, and form the basis for this report. 12~2 February 1983
Annals of Emergency Medicine
75/21
SMALL BOWEL PERFORATION Phillips et al
Figure. Field triage criteria for trauma center transfer. The group consisted of four women and eight men between the ages of 16 years and 64 years. Reliable data were not available on the precise mechanism of injury in each case. The available information has been excluded because of the subjectivity and lack of verification of reports from the accident scene. All patients were victims of blunt trauma sustained in motor vehicle accidents, and all had met the field triage criteria (Figure) for helicopter transport to our institution. The elapsed time from injury to arrival did not exceed one hour. Peritoneal lavage is used liberally in our institution for the diagnosis of intraperitoneal hemorrhage following blunt trauma. Our technique and our criteria (Table 1) for interpreting the results of peritoneal lavage have been previously published. 1'~ Patients who have positive findings on peritoneal lavage are routinely explored. Patients with negative results are followed clinically based on the findings of serial examinations. Patients whose lavage cell counts are in the indeterminate range are usually managed by leaving the peritoneal lavage catheter in place and repeating the lavage two to four hours later by infusing another 1,000 cc of saline (20 cc/kg in children) through the same catheter. Positive results on this second lavage are d e t e r m i n e d by using the same criteria as on the first, and result in laparotomy. Negative results on the second lavage are interpreted as truly negative, and the patients are followed clinically. When the result of the second lavage also falls in the indeterminate range, the surgeon has the option of performing a third lavage using the same technique and criteria after another two to four hours, or acting on the trend of the cell counts. The Procedure in this situation is not uniform. However, a patient with an initial cell count of 60,000 RBC/mm 3 that increases to 85,000 on a second lavage is likely to be explored surgically. If the initial cell count were 80,000 R B C / m m 3 and fell to 60,000 on second lavage, the patient is likely to be observed clinically. If two serial p e r i t o n e a l lavages b o t h had cell counts of 75,000 RBC/mm 3, the patient likely would be subjected to a third peritoneal lavage.
A. Trauma combination: head, chest, abdomen, extremity• B. Crush-blunt trauma: chest, abdomen, pelvis• C. Penetrating chest wound: gunshot wound, stab, impaled objects. D. Injury with severe hemorrhage: systolic blood pressure < 80. E. Paralysis or vascular impairment: one or more extremities• F. Unconscious trauma patient: loss of consciousness > 5 minutes. G. Head trauma: pupils unequal. H. Penetrating wounds of the abdomen• I. Patient extricated from accident wreckage after 30 minutes. J. Amputation of finger, hand, extremity.
TABLE 1. Criteria for interpreting results of peritoneal Iavage Positive:
Lavage fluid exits Foley catheter or chest tube. Return of > 10 cc of frank blood upon aspiration of dialysis catheter. > 100,000 RBCs per mm 3. > 500 WBCs per mm 3.
Negative:
< 50,000 RBCs per mm 3, < 100 WBCs per mm3•
Indeterminate:
50,000-100,000 RBCs per mm 3. 100-500 WBCs per mm 3.
The d e t e r m i n a t i o n s of amylase, bilimbin, and bacterial counts are not routinely performed on peritoneal lavage fluid in our institution, nor is the serum amylase. Charts were analyzed for the clinical status of the patients at the time of admission, the results of peritoneal lavage, the presence of associated injuries, mortality, and complications. Particular attention was focused on the ability to make the diagnosis at the time of admission, using the combination of physical examination and peritoneal lavage.
all eight. One patient was in profound shock on admission and had a visibly distending abdomen. She was explored i m m e d i a t e l y on the basis of these findings alone. Three of the patients in this group had associated intraperitoneal visceral injuries that contributed to their positive lavage findings (Table 2). Five p a t i e n t s had major orthopedic injuries. Group II consisted of three patient s in w h o m the diagnosis of intra-abdominal injury requiring laparotomy was not made at the time of initial assessment.
RESULTS
Case Number One
All patients fell into one of two clinical categories. Group I consisted of nine patients with severe blunt multiple trauma. In this group t h e diagnosis of small bowel p e r f o r a t i o n was n o t m a d e preoperatively in any patient because the findings were not specific fo r this injury. However, all these patients were either in shock on admission (six patients) or had sustained serious head injury. Peritoneal lavage was performed in eight (89%), and the initial lavage was unequivocally positive in
This patient underwent peritoneal la-cage because his s e n s o r i u m was altered by alcohol intoxication at the t i m e of the motor vehicle accident. He was n o t hypotensive, b u t bowel sounds were absent. Initial lavage findings included an RBC count of 80,000/mm 3, and therefore the lavage was repeated at four hours according to the standard procedure. The second p e r i t o n e a l lavage RBC count was 60,000. The patient was followed clinica'lly, and within six hours of his second lavage (12 hours after injury)
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Morbidity and Mortality TABLE 2. Associated injuries by group Group I Serious head injuries Major orthopedic injuries Other intra-abdominal injuries Spleen and liver ColonShock on admission Isolated small bowel injury Multiple small bowel perforations
Group II 1
Total number of patients
he developed clinical peritonitis with localized abdominal tenderness and rebound tenderness. Exploration was performed at this time, and a small bowel perforation was discovered and repaired.
Case Number Two This patient was a 23-year-old man who was in an agitated condition when first evaluated following blunt trauma to the trunk in a motor vehicle accident. His mental status appeared to be the result of an acute drug intoxication. His blood pressure was 110/80 m m Hg, and his pulse was 90 beats per minute. There was no external evidence of abdominal trauma and bowel sounds were present, but the findings of abdominal palpation were uninterpretable because the patient was agitated and u n a b l e to cooperate with the examination. Peritoneal lavage was performed. The RBC count was only 7,100/ram 3, but the WBC was equivocal at 345/mm 3. In four hours peritoneal lavage was repeated with an RBC count of 22,400/ m m 3, but the WBC count was now grossly elevated at 8,400/mm 3. Physical examination at this time revealed localized abdominal tenderness and clinical signs of early peritonitis. Exploration was performed on the basis of both the lavage results and the change in clinical findings. An isolated small intestinal perforation was found and repaired. Ornental adhesions at the site of the injury had minimized intestinal spillage. Recovery was uncomplicated.
Case Number Three The most distressing of our indeterminate cases was that of a 20-year-old woman who sustained a pelvic fracture in a high-speed collision. Peritoneal lavage was performed. Initial 12:2 February 1983
results revealed RBCs of 15,000/mm3; WBCs were not recorded. For reasons that remain obscure, the lavage was repeated twice in spite of the initial negative result. Questionable physical findings appear to have motivated the surgical team to doubt the results of the initial lavage. The second RBC count was 45,000/ram 3, and the third, 96,000. These rising RBC counts were attributed to intraperitoneal leakage of cells from the retroperitoneal hematoma caused by the patient's pelvic fracture, a phenomenon which is known to occur. 3 Five days post injury the patient developed clinical evidence of intra-abdominal sepsis including fever, leukocytosis, and abdominal tenderness. Surgical exploration revealed a subhepatic abscess resulting from a full-thickness small bowel perforation. Omental adhesions had sealed the perforation and limited free peritoneal soilage. The subhepatic abscess apparently resulted from contamination occurring in the period immediately following the initial injury.
Associated Injuries Of the nine patients in Group I, two had isolated small bowel injuries, w i t h bleeding from the mesentery being responsible for the positive lavage. In the remaining seven, there were five major orthopedic injuries, three severe head injuries, and four associated visceral injuries (two splenic ruptures, both of which had associated minor liver lacerations, and two injuries to the colon) (Table 2). In Group II (the occult visceral injury group), one of the three patients had a major orthopedic injury (a fractured pelvis) and two had isolated small bowel perforation. Four of the total of 12 patients had multiple perforations, and all of these fell into Group I. Annals of Emergency Medicine
Two patients in the series died, for an overall mortality of 17%. One, who was admitted in profound shock, died within 48 hours of admission from multiple organ failure that included acute anuric renal failure and sepsis. The other was discharged ten days following admission after an apparently uncomplicated hospital course. He was readmitted in septic shock with a blood pressure of 90/50 m m Hg, 48 hours after discharge. At exploration he was found to have ten feet of gangrenous bowel in the area of the small intestinal anastomosis. He died ten days postoperatively of multiple organ failure. Six patients in this series (50%) developed clinical sepsis (Table 3). This included one patient who developed a subhepatic abscess and wound dehiscence five days after injury, one patient who also had a colon injury and developed a pelvic abscess and wound dehiscence, one patient whose occult small bowel injury was not diagnosed until she developed a subhepatic abscess and clinical signs of intra-abdominal sepsis five days after injury, and one patient who developed a subcutaneous wound infection. Two patients experienced clinical septic episodes and were successfully treated with antibiotics and supportive measures. A definite source of infection could not be identified in either patient. Neither of the two patients whose diagnosis was delayed for four to six hours awaiting clinical evidence of localized peritonitis or a positive peritoneal lavage WBC count experienced septic complications. Neither of these two patients was ever in shock. Hospital stays ranged from six to 43 days. The two patients with the longest hospital stays included one patient with multiple perforations and the one whose diagnosis was delayed for five days. Both required exploration for intraperitoneal abscess.
DISCUSSION From this review several important aspects of blunt small bowel injury become apparent. Although uncommon, 4'5 this injury can be responsible for a surprising degree of morbidity. In the majority of patients the diagnosis will be made at operation, based on clear clinical evidence of hemorrhagic shock of abdominal origin or as the result of an initial positive peritoneal lavage performed at the time of ad77/23
SMALL BOWEL PERFORATION Phillips et al
mission. In a minority of patients early diagnosis of this injury may prove difficult. Physical findings at the time of initial examination may be limited, and initial peritoneal lavage results may be negative. The presence of head injury or drug or alcohol intoxication m a y further obscure the diagnosis. Finally, the presence of other easily diagnosed injuries, s u c h as C N S or orthopedic injuries, may detract attention from the abdomen. The three theoretical mechanisms of p e r f o r a t i n g s m a l l b o w e l injury r e s u l t i n g f r o m b l u n t t r a u m a are crushing, shearing, and bursting. 6-9 A crushing injury results from direct impact of the small bowel against the anterior portion of the vertebral column. A shearing injury occurs when the inertial effects arising from highspeed impact exceed the equalizing force of the small bowel at the attachment points, ie, the ligament of Treitz and the cecum. A bursting injury can result from blunt trauma in which the force of impact is transmitted through the abdominal wall, resulting in disruption secondary to a rapid increase in intraluminal pressure. Peritoneal lavage has been the single most reliable diagnostic tool used at our institution for the evaluation of blunt abdominal trauma. The accuracy rate of peritoneal lavage for all our patients with abdominal trauma has been 97.8%. 1° However, in this series of patients with small bowel injuries the accuracy was only 75%, due to a false-negative rate of 25%. Engrav et a111 reported missing 16% of small bowel injuries using peritoneal lavage. Although not statistically significant, our experience indicates that most conscious patients with this injury will probably develop such clinical evidence of peritonitis as.localized abdominal tenderness, localized rebound tenderness, and loss of bowel sounds within 12 hours of injury. Serial abdominal examinations by the same examiner, and consideration of repeat peritoneal lavage using both red and white blood cell counts are important ways of pursuing the diagnosis in the group of patients with equivocal findings on admission physical examination and indeterminate results on initial peritoneal lavage. New abdominal findings must be interpreted seriously, and exploratien m u s t be u n d e r t a k e n in q u e s t i o n a b l e cases. Nonetheless, this injury may remain occult, as demonstrated by one patient in our series and another reported in 24/78
TABLE 3. Septic and w o u n d complications Total Subhepatic abscess Wound dehiscence Pelvic abscess Subcutaneous wound infection Occult sepsis responsive to antibiotics Total number of patients with septic complications Total number of patients
the literature in w h o m the diagnosis was delayed 35 days. 12 The diagnosis of small bowel perforation can be missed easily in the patient whose sensorium is significantly altered by head trauma or intoxicants. In these patients the use of serial peritoneal lavage utilizing both red and white blood cell counts 13'15 may provide the only clue to the presence of a significant intraperitoneal injury. In this setting, an elevated and rising serum amylase on serial determinations may contribute to the diagnosis. T h e routine use of either serum, 16'17 or peritoneal lavage fluid 13 amylase determinations is not cost effective and is likely to be misleading.13,16,17 Septic complications were promin e n t in our series of patients. Alt h o u g h it r e m a i n s speculative, we believe that it is the combination of intraperitoneal soilage and the nonspecific i m m u n o l o g i c defect associated with shock that are responsible for the high incidence of sepsis in our series of patients. The picture is somewhat clouded by the fact that one of our patients who developed intra-abdominal sepsis also sustained a colon injury, and another patient's injury was not diagnosed and treated until sepsis supervened five days later. Two of our patients who had delays in diagnosis of four to six hours, but who were not in shock at any time, experienced u n c o m p l i c a t e d postoperative courses. We have identified only three patients in w h o m this diagnosis was missed by peritoneal lavage:during a t i m e period in w h i c h nearly 3,000 peritoneal lavages were performed for blunt abdominal trauma. Thus these data do not diminish the role of peritoneal lavage in blunt trauma. However, because peritoneal lavage is known Annals of Emergency Medicine
Group I
Group II
2 2 1 1 2
I 2 1 1 2
1
6
5
1
12
9
3
to have an inaccuracy rate of from 3% to 5%, 1'~'1°'1s-~° and 25% of our patients had a false-negative initial lavage, small bowel perforation may be among the injuries that can be present even in the presence of negative study. REFERENCES 1. Du Priest RW, Khaneja SC, Rodriguez A, et al: Technique for open diagnostic peritoneal lavage. Surg Gynecol Obstet 147:241-243, 1978. 2. Soderstrom CA, Du Priest RW, Cowley RA: Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstet 151:513-518, i980. 3. Hubbard SG, Bivins BA, Sachatello CR, et al: Diagnostic errors with peritoneal lavage in patients with pelvic fractures. Arch Surg 114:844-846, 1979. 4. Shuck JM, Lowe RJ: Intestinal disruption due to blunt abdominal trauma. Am J Surg 136:668-673, 1978. 5. Cerise EJ, Scully JH: Blunt trauma to the small intestine. J Trauma 10:46-50, 1970. 6. Sube J, Ziperman HH, McIver WJ: Seat belt trauma to the abdomen. Am J Surg 113:346-350, 1967. 7. Snyder CJ: Bowel injuries from automobile seat belts. Am J Surg 123:312-316, 1972. 8. Geoghegam T, Brush BE: The mechanism of intestinal perforation from nonpenetrating abdominal trauma. Arch Surg 73:455-464, 1956. 9. Williams RD, Sargent FT: The mechanism of intestinal injury in trauma. J Trauma 3:288-293, 1963. 10. Du Priest RW, Rodriguez A, Khaneja SC, et al: Open diagnostic peritoneal lavage in blunt trauma victims. Surg Gynechl Obstet 148:890-894, 1979. . 1i. Engrav LM, Benjamin CI, Strate RG, et al: Diagnostic peritoneal lavage in blunt abdominaI trauma. J Trauma 15:854-859, 1975. 12'. Flaisham HA, Griffith GL, Bivins BA: Delayed perforation of the small bowel fol12:2 February 1983
lowing blunt abdominal trauma. ] Ky Med Assoc 77:294-296, 1979. t3. Alyono D, Perry JF: Value of quantitative cell count and amylase activity of peritoneal lavage fluid. J Trauma 21:345-348, 1981. 14. Brotman S, Phillips TF, Cowley RA: The importance of serial white blood cell counts in diagnostic peritoneal dialysates in blunt trauma. Md State Med J 30:2, 1981.
15. Root H, Keizer PJ, Perry JF: The clinical and experimental aspects of peritoneal response to injury. Arch Surg 95:631, 1967. 16. Moretz JA, Campbell DP, Parker DE, et al: Significance of serum amylase level in evaluating pancreatic trauma. Am J Surg 130:739-741, 1975. 17. Olsen WR: The serum amylase in blunt abdominal trauma. J Trauma 13:200204, 1973. 18. Perry JE, Strate RG: Diagnostic peri-
ABEM
Notice
toneal lavage in blunt abdominal trauma: Indications and results. Surgery 6:898-901, 1972. 19. Hunt KE, Garrison RN, Fry DE: Perforating injuries of the gastrointestinal tract following blunt abdominal trauma. Am Surgeon 45:101-104, 1980. 20. Ahmad W, Polk HC: Blunt abdominal trauma, a prospective study with selective peritoneal lavage. Arch Surg I1:489-492, 1976.
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On June 30, 1988, the practice option will t e r m i n a t e for those physicians wishing to m e e t the credential requirem e n t s of the A m e r i c a n Board of Emergency Medicine's certification examination. Practice, teaching, or CME a c c u m u l a t e d after the above date m a y not be used to satisfy the practice requirements. Q u e s t i o n s should be directed to ABEM, 1305 A b b o t t Road, Suite 101, East Lansing, MI 48823; 517/332-4800.
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