Introduction
A 41-year-old male sawmill worker was loading logs onto an edger (cuts
logs into boards) when the machine propelled a 2x4 back towards him at
a high velocity. The patient was struck in the right upper quadrant and
was knocked to the ground without loss of consciousness. On arrival at
the hospital, the patient was alert and reported pain radiating from his
right groin to right shoulder.
Abdominal CT scan revealed a subcapsular hepatic hematoma encompassing
approximately 50% of the liver with perihepatic fluid and a contusion of
the right colon. No free air was noted in the abdominal cavity.
On post-injury day one (PID 1) the patient was alert but with
abdominal distention and hypoactive bowel sounds. On PID 2 the patient
was noted to have increased pain and lethargy, as well as a significant
left shift in his white blood cell count. Another CT scan with IV and oral
contrast was ordered. Can you find the pathologic elements which indicate
why the patient has taken a turn for the worse?
Answer
The findings of retroperitoneal air and air in the prerenal space indicate
perforation of
the duodenum. The large inflammatory process in the area of the
bowel, as well as
the indistinct borders of the left kidney and psoas muscle, indicate
that the trauma
may have led to necrosis and perforation of other parts of the
bowel.
In fact, on exploratory celiotomy, the patient was noted to have
perforation of
proximal third portion of the duodenum, ischemic necrosis of
the right colon with
perforation, laceration of the colonic mesentery, extensive visceral
edema, and
retroperitoneal abscess with purulent fluid throughout the entire
abdomen and pelvis.
Case
Discussion
After the second CT scan, the patient was transferred to the University
of Alabama
at Birmingham (UAB) trauma service. On arrival, he was intubated
as a result of
declining pulmonary function. He was tachycardic, normotensive,
and had significant
abdominal distention. Broad-spectrum antibiotics were begun.
On exploratory celiotomy, the patient was noted to have perforation
of proximal third
portion of the duodenum, ischemic necrosis of the right colon
with perforation,
laceration of the colonic mesentery, extensive visceral edema,
and retroperitoneal
abscess with purulent fluid throughout the entire abdomen and
pelvis. Right
hemicolectomy, repair of third portion of duodenum, and temporary
abdominal wall
closure were performed. Because of extensive visceral edema,
neither a primary
anastomosis nor a temporary ostomy was felt to be a safe option
for the patient. A
plan was made for delayed re-establishment of intestinal continuity
once the edema
reduced.
The patient was stabilized in the surgical intensive care unit
(SICU). He was
continued on broad-spectrum antibiotics, including fluconazole
for fungal coverage,
for a planned total course of 14 days. The patient remained afebrile.
On PID 5, the patient was taken back to the operating room to
surgically evaluate the
potential for creating an ostomy and primary closure of the abdominal
wound.
Extensive visceral and mesenteric edema eliminated the option
of diversion with
ileostomy or end colostomy. An ileotransverse colostomy (connection
from the ileum
to the transverse colon) was performed. Duodenal repair was noted
to be intact with
no evidence of a leakage. An enterotomy was made to facilitate
decompression of
the extensive intraluminal fluid. Succus entericus (2.5 L) was
removed from the
intestinal lumen. The retroperitoneal sepsis appeared well controlled.
The abdomen
was not closed primarily due to the persistent visceral edema.
Several days later, the
patient was taken back to surgery for reexploration of the abdomen
and closure of
the abdominal wound with an absorbable mesh.
On PID 14, the patient was extubated. He was placed on a nasal
cannula and
subsequently transferred out of SICU to the step down unit for
continued
convalescence.
The patient was discharged on PID 52. He was later seen in the
outpatient clinic,
where he reported walking approximately one mile per day and
having a good
appetite. Abdominal wall reconstruction for his ventral hernia
will be addressed by
the plastic surgeons in 6 to 8 months.
CT
versus DPL or US for Blunt Abdominal
Trauma
Diagnostic peritoneal lavage (DPL), ultrasonography (US), and
computed
tomography (CT) scanning are the diagnostic studies most commonly
used to
determine the necessity of celiotomy in patients with blunt abdominal
trauma.
The preferred method in most centers is DPL. It is invasive, but
it may be performed
rapidly, and is inexpensive and accurate. Because of its speed,
this modality is
especially useful for determining the presence of intra-abdominal
bleeding in
hypotensive patients with blunt trauma. However, DPL misses injuries
to the
diaphragm, and cannot rule out injury to retroperitoneal structures.[1]
In blunt trauma, a "positive" lavage is indicated by an RBC count
greater than
100,000/mL, a WBC count greater than 500/mL, or the presence
of amylase or bile.
Aspiration of free nonclotting blood on insertion of the dialysis
catheter also qualifies
as a positive lavage. Contraindications to using DPL as an indication
for celiotomy
include previous abdominal surgery, significant obesity, and
pregnancy.
Ultrasonography may also be used to ascertain the presence of
intra-abdominal
hemorrhage in the unstable patient. This technique can be easily
repeated at intervals
to identify ongoing hemorrhage. However, the sensitivity of US
is highly
operator-dependent.[2] This modality is frequently utilized in
Europe, and is gaining
widened acceptance in the United States for the assessment of
the unstable patient.
In comparison to DPL, computed tomography (CT) is noninvasive,
but is time
consuming to perform as well as expensive. It is accurate, but
in many hospitals, this
diagnostic study misses gastrointestinal perforations or ruptures.
Because of their
complimentary diagnostic capabilities, DPL and CT may both be
needed to diagnose
and manage the same stable patient.[1]
According to one study, limiting CT to the evaluation of patients
with DPL-positive
results and hemodynamic stability is safe, reduces charges, and
results in a lower rate
of nontherapeutic celiotomies compared with DPL alone.[3]
References
1.Feliciano DV: Diagnostic Modalities in Abdominal
Trauma. Peritoneal lavage,
Ultrasonography, Computed Tomography
Scanning, and Arteriography.
Surgical Clinics of North America 71(2):241-56,
1991 Apr.
2.Feliciano DV, Moore EE, Mattox KL: Trauma, Stamford
Connecticut,
Appleton and Lange, 1996.
3.Schreiber MA, Gentilello LM, Rhee P, et al: Limiting
Computed Tomography
to Patients with Peritoneal Lavage-Positive
Results Reduces Cost and
Unnecessary Celiotomies in Blunt Trauma.
Archives of Surgery
131(9):954-8; discussion 958-9, 1996
Sep.
About
the Authors
P.A. Nixon is MS-II at the University of Alabama at Birmingham School
of Medicine. J. Hanissian is MS-IV at the University of Pennsylvania
School of Medicine. Dr. Lepore is a fourth year general surgery
resident and Dr. Rue is Associate Professor of Surgery and Chief
of the Section of Trauma, Burns and Surgical Critical Care Services, at
the University of Alabama at Birmingham Medical Center in Birmingham, Ala.
