The utility of Sonography in the assessment of Blunt Abdominal Trauma

The utility of Sonography in the assessment of Blunt Abdominal Trauma

Usama Murad Ibraheem,. Ayoub Mutlak Zedan Department of Surgery ,College of Medicine,University of Tikrit

ABSTRACT
Objectives: To evaluate the diagnostic value of ultrasound in detecting intraabdominal injuries in patients with Blunt Abdominal Trauma (BAT). Patients and Methods: The study was conducted in the department of radiology .A total of 30 patients with blunt abdominal trauma were included. They all underwent Ultrasonography (US) followed by Computed Tomographic (CT) scan of abdomen. Sensitivity, specificity, and accuracy of US in detecting intraabdominal injury were calculated keeping CT findings as gold standard. The cases in which laparotomy was performed; the surgical findings were taken as the standard. Results: US examinations were positive in 16 patients. Of these, 8 (50%) had free intra-abdominal fluid only, 7 (43.8%) had both free intraabdominal fluid and intraabdominal organ injury and 1 (6.2%) had intra-abdominal organ injury only. True-positive findings were seen in 12 (75.0%) of these on CT and/or laparotomy.There was one false negative case. Sensitivity, specificity, and accuracy of US in detecting intraabdominal injury were 93.3%, 86.6%, and 90%, respectively. Conclusion: Ultrasonography has high diagnostic performance in the screening the patients with blunt abdominal trauma.

Introduction
Trauma is the third leading cause of death in the United States and is the leading cause of death in the age group of 15 to 44 years (1).Blunt abdominal trauma (BAT) usually occurs due to road traffic accidents (RTA), fall from heights or during sports (2). Prevalence of intraabdominal injury (IAI) varies widely, ranging from 7.7% to 65%. Rapid diagnosis is essential and appropriately prioritizing diagnostic work up and treatment is critical to ensure patient survival (3, 4). CT scanning of the abdomen can depict such injuries accurately and is relatively noninvasive. It is not usually the first option, because it is relatively expensive and requires radiation exposure and injection of contrast material.The CT has higher accuracy in assessment of solid organ injuries and other injuries related to trauma (5).US is the primary imaging modality of choice for diagnosis of IAI(2,5). It is non invasive, rapid, repeatable, relatively inexpensive and a reliable diagnostic tool for assessment of presence of abdominal fluid, and in detecting liver, spleen and kidney injuries (2, 5, and 6). During the so-called golden hour in patients with trauma and shock, if there is intra-abdominal bleeding, the probability of death increases by about 1% for every 3 minutes that elapses before treatment(7). The primary goal of abdominal US in the major trauma setting, is to detect any intra-abdominal accumulation of free fluid and other features that may be suggestive of injury to one or more organs (5). In the hands of most operators, ultrasound will detect a minimum of 200 mL of fluid (8). This study designed to assess the diagnostic value of Sonography in the assessment of Blunt Abdominal Trauma

Subjects and Methods

Prospective study was conducted during a 10-month period(January 2007 to October 2007) at Tikrit teaching hospital ultrasound unit. Patients with blunt abdominal trauma and strong clinical suspicion of IAI, who were hemodynamically stable were included in the study who subsequently underwent abdominal CT ,clinical observation or surgery or all. . The interval between sustaining injuries and the first ultrasonographic examinations was less than 48 hours. Those who were already operated on, pregnant patients, those who had burns were excluded. US examinations were performed with a 3.5/ 5.0-MHz convex probe on SIEMENS Doppler US Machine (Model: versa pro). US examinations were completed within 1015 minutes.

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The utility of Sonography in the assessment of Blunt Abdominal Trauma Patient is scaned in a supine position.The 7 areas evaluated for fluid are the right and left upper quadrants,epigastrium,the right and left paracolic gutters,the retroperitioneum, and the pelvis.In addition, the liver, spleen, and kidneys are scanned for potentially traumatic abnormalities.Hemoperitoneum can easily be seen in its varying echogenicity depending on the stage of transition of the blood. Patients were not selected for further abdominal spiral CT (SIEMENS plus four)unless US results were considered positive for the presence of free fluid or organ injury.Visceral organs were evaluated for parenchymal abnormalities consisting of intraparenchymal hematomas, lacerations, and/or geographic zones of echotextural heterogeneity. Free fluid with attenuation value>30 Hounsfield Units (HU) was labeled as hemoperitoneum. The decision to manage patients either conservatively or proceed to laparotomy was made by the attending surgeon based on clinical condition along with US and CT results. US findings were compared with the findings obtained by CT and laparotomy. CT was used as the diagnostic standard.. Patients were followed up until they were discharged from the hospital. Patients who were followed up by clinical observation and then discharged were considered as being normal. Sensitivity, specificity, and accuracy of US were calculated. With US free fluid was identified in total 15 Patients while organ injury was detected in 8 patients (Table 2). Out of 16 positive cases on US, 14patients were confirmed on CT as IAI. In one patient who had no positive finding on US, GI system injury without free fluid was detected on CT (false negative). Thus, total positive cases on CT were 15.Out of these 15 patients, 7(47 %) had free fluid only, 6 (40 %) had free fluid and organ injury and 2 (13 %) patients had organ injury only (Table 2). The frequency of organ injury as detected on CT is shown in Figure 1. Total 4 patients had splenic injuries. Out of these, 2 had grade 2 injuries, 1 had grade 3 and 1 had grade 4 injury(Fig 3). Two patients had liver injuries and out of these one had grade 2 injury (Fig 4) while one had grade 3 injury. One renal injury was of grade 3. US findings were compared to CT and laparotomy findings (Table 2). US detected isolated free fluid in 8 patients. On CT one (12.5%) out of these 8 patients was labeled as negative for IAI (false positive) as minimal pelvic free fluid on US could not be attributed to hemoperitoneum based on attenuation values which were less than 30 Hounsfield Units (HU).Out of the 7 patients, who had both free fluid and intraabdominal organ injury detected by US, 1 (14.2 %) was declared negative for IAI (false positive) as free fluid /organ injury was not confirmed by CT and it was a focal liver fatty infiltration identified erroneously as an injury. CT correlated well with surgical findings in all five operated cases. US results after comparison revealed that 14 of 16 (87.5%) were true positive, 2 of 16 (12.5%) false positive, 13 of 14 (93.0%) true negative, and 1 of 14 (7%) false negative (Table 3).

Results
Out of 30 patients 22 (74.3%) were males and 8 (25.7%) females. The mean age was 34.9417.42 years (range 5-70 years). The causes of BAT are summarized in Table 1.Five (17%) patients had laparotomy, while the remaining 25 (83%) were followed with clinical observation until the time of discharge. With US, positive findings were present in 16 (53%) patients. Of these, 8 (50%) had free intra-abdominal fluid only, 7 (43.8%) had both free intra-abdominal fluid and intraabdominal organ injury and 1 (6.2%) had intraabdominal organ injury only.

Discussion
Initial US images are of sufficient diagnostic quality.It is particularly important to avoid unnecessary imaging studies in children and pregnant women (9). The present study the male prevalence was comparable to Shiryazdi study (2).The most frequent cause of BAT in our study was road traffic accident as has been reported by Kshitish et al study (10). There was one false positive result US detected free fluid without

Tikrit Medical Journal 2010; 16(1):86-91

The utility of Sonography in the assessment of Blunt Abdominal Trauma organ injury in total 8 patients. Out of 8, US detected free fluid without organ injury,one patients was labeled on CT as negative for IAI (false positive). The patient was female and she had minimal free fluid in pelvis, which was later on not confirmed to be hemoperitoneum by CT.In 30%40% of women of reproductive age, fluid collections of up to 50mL in the pouch of Douglas are considered physiologic, although the exact underlying mechanism of accumulation is not clear. Amounts of free fluid that exceed 100 mL should always be regarded as pathologic(11)..In a study by Richards et al. on 744 patients, out of 51 patients who had free fluid identified by US, 9 were false positive results; of these 9 patients 7 were female who had pelvic free fluid(12)... Hence, most of these false positive results were reported to be originating from the physiological fluid observed in females. Our study showed that 4 patients out of 8 had splenic injury with frequency of 50 %.The frequency of hepatic injury in our study is 25% which is contrary to a Khan et al study in which liver was most commonly injured organ (35%) followed by spleen (32%), but it is in accordance with study by Ghazanfar et al in which frequency of liver injury is 21%.(13,14 ) Two cases (22%)of organs injury with no associated free fluid(out of the total 9)seen on CT (one of them only diagnosed on US).Our findings are lower in accord with those of a study by Shanmuganathan et al (15) ,who reported that 34% of patients with blunt trauma with organ injury did not have associated free fluid at admission CT. (15 ) In the screening of BAT patients with US, the most important problem is false negative results, not the false positive ones. In our study, there was only one false negative result. It is clear that both in the previous studies (16, 17) and our current study, one of the most important reasons that has led to false negative results was GI injury. When no free fluid is present in the abdomen, US is not successful in detecting the GI injuries. An isolated solid organ injury is another reason for false negative results (16,17 ). The sensitivity, specificity, and accuracy of US in BAT were hitherto reported to be 81% to 94%, 86% to 100%, and 86% to 98%, respectively (18). Sensitivity, specificity, and accuracy of US in detecting intraabdominal injury in our study were 93.3%, 86.6%,and 90%, respectively. Our results are comparable with the results obtained by Atif et al with a sensitivity of 93%, sepecifity of 85% & an accuracy of 88.5%(19) .

Conclution:
In BAT patients, US should be the first technique of choice for diagnosis. Sonography is a fast, simple, noninvasive, and readily available screening examination.Sonography is useful as a diagnostic tool for detecting intraabdominal injuries but is less sensitive for detecting bowel and mesenteric injuries.If US findings are not normal or unsatisfactory, then CT examination can be performed provided the patient is stable. with negative US results may undergo A 12-24 hour period repeat ultrasound, clinical observation or CT at the discretion of the clinician, on the basis of physical and laboratory findings

References
1. Jacobs BJ, Jacobs LM. Epidemiology of trauma. In: Feliciano DV, Moore EE, Matrtox KL (eds). Trauma. Stamford, CT: Appleton &lange, 1996:pp. 15-301. 2. Shiryazdi M, Modir A. Study of the diagnostic value of ultra sonography in blunt abdominal traumas. Pak J Med 2005; 44:3:130-32. 3. Brown CK, Dunn KA, Wilson K. Diagnostic evaluation of patients with blunt abdominal trauma: a decision analysis. Acad Emerg Med 2000;7:385-96. 4. Richards JR, Knopf NA, Wang L, McGahan JP. Blunt abdominal trauma inchildren: evaluation with emergency US. Radiology 2002;222:749-54.

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The utility of Sonography in the assessment of Blunt Abdominal Trauma

5. Shafiq M, Khokhar RA. Blunt abdominal trauma: diagnostic modalities andmanagement. J Surg 2001; 23-24:4-9. 6. Lingawi SS, Buckley AR. Focused abdominal US in patients with trauma.Radiology 2000;217:426-9. 7. Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L,Mode CJ. Time to laparotomy for intraabdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 2002;52:420425. 8. Branney SW, Wolfe RE, Moore EE, et al: Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma 1995:39: 375-380. 9. Brown MA, Sirlin CB, Farahmand N, Hoyt DB,Casola G. Screening sonography in pregnant patients with blunt abdominal trauma. J Ultrasound Med 2005;24:175181. 10. Kshitish M, Sushma V, Sanjay T, Srivastava DN. Comparative evaluation of ultrasonography and CT in patients with abdominal trauma: a prospective study.Indian J Radiol Imag 2000;10:237-43. 11. Sirlin CB, Casola G, Brown MA, et al. US of blunt abdominal trauma: importance of free pelvic fluid in women of reproductive age. Radiology 2001;219:229235. 12. Richards JR, Schleper NH, Woo BD, Bohnen PA, McGahan JP. Sonographic assessment of blunt abdominal trauma: a 4-year prospective study. J Clin Ultrasound 2002;30:59-67. 13. Ghazanfar A, Choudry ZA, Zubair M, Nasir SM, Khan SA, Ahmed W.Abdominal solid visceral injuries in blunt abdominal trauma: an experience in busy surgical unit of

Mayo Hospital, Lahore. Ann King Edward Med Coll 2001;7:85-7. 14. Khan JS, Iqbal N, Gardezi JR. Pattern of visceral injuries following blunt abdominal trauma in motor vehicular accidents. J Coll Physicians Surg Pak 2006;16:645-7. 15. Shanmuganathan K, Mirvis SE, Sherbourne CD, Chiu WC, Rodriguez A. Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential Limitation of screening abdominal US for trauma. Radiology 1999; 212:423430. 16. Tas F, Ceran C, Atalar MH, Bulut S, Selbes B, Isik AO. The efficacy of ultrasonography in hemodynamically stable children with blunt abdominal trauma:a prospective comparison with computed tomography. Eur J Radiol 2004;51:91-6. 17. Yoshii H, Sato M, Yamamoto S, Moteqi M, Okusawa S, Kitano M, et al.Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998;45:45-51. 18. Bakker J, Genders R, Mali W, and Leenen L. Sonography as the primary screening method in evaluating blunt abdominal trauma. J Clin Ultrasound 2005; 33:155163. 19. Atif Latif, Muhammad Ashraf Farooq, Muhammad Adeel Azhar. Diagnostic Value of Ultrasonography in Evaluation of Blunt Abdominal Trauma. Rawal Med J 2008; 33:154-159.

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The utility of Sonography in the assessment of Blunt Abdominal Trauma Table 1. Causes of BAT (n=30). Number 19 6 3 2 30

RTA

Percentage 62.86% 20.00% 11.54% 5.70% 100%

Fall From height Assault Others Total

Table 2. Conformity of US findings with CT findings (n=30

Ultrasonography FF Positive FF OI FF + OI Negative Total

7 7

Computed Tomography Positive Negative OI

1 1 2

Total
8 1 7 14 30

FF + OI
6 6 1 1 13 15

Table 3. Diagnostic value of US in detecting IAI. Parameter Data %

Sensitivity Specificity Accuracy

14 of 15 13 of 15 27 of 30

93.3 86.6 90

25% 50% 12.5% 12.5%

LIVER RENAL BOWEL SPLEEN

Fiqure 1.The frequency of organ injury as detected on CT.

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The utility of Sonography in the assessment of Blunt Abdominal Trauma

Figure 2.(a) Longitudinal (right) and transverse (left) views of the left upper quadrant, obtained at the initial US examination, show parenchymal hyperechogenicity (arrowhead) and a small free perisplenic fluid collection (arrow). In the transverse plane, the caudal splenic edge is irregular in contour. The injury was rated grade II by the US image..(b) CT image for the same patient

Figure 3 (a) Transverse US view of the subxiphoid region, obtained at an initial US examination, shows an area of slight hyper-echogenicity in the left lobe of the liver (arrow), a finding suggestive of a laceration. A small collection of free fluid also was visible in the pouch of Douglas. (b) Abdominal CT image shows an area of decreased attenuation (arrow) in the liver, a finding that helped confirm the diagnosis of liver laceration.

Tikrit Medical Journal 2010; 16(1):86-91

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