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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 876-879

Role of ultrasonography in blunt abdominal trauma


1 Radiology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Radiology Department, Al-Moneira Hospital, Cairo, Egypt

Date of Submission26-Jul-2016
Date of Acceptance06-Nov-2016
Date of Web Publication15-Nov-2017

Correspondence Address:
Sharehan Abdelmonem
El-Marg El-Gedida, Cairo, 11721
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.218269

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  Abstract 

Objective
The aim of the study was to assess the role of ultrasonography (US) focused assessment with sonography in trauma (FAST) at the time of presentation and ultrasound repeated after 12–24 h in early diagnosis of intra-abdominal injury (IAI) following blunt abdominal trauma (BAT) and for follow-up.
Background
US was used in patients with IAI. Trauma is the most common cause of mortality. The most common mechanisms resulting in BAT among patients were motor vehicle collisions (73%), motorcycle collisions (7%), auto–pedestrian collisions (6%), and falls (6%).
Patients and methods
This is a prospective study of 50 patients presented to the Emergency Room of Menoufia University Hospital with BAT who underwent US and FAST examination at the time of presentation and were followed up with US after 12–24 h. Of them, 12 patients were hemodynamically unstable, six patients had severe intra-abdominal hemorrhage and entered the operation theater urgently after FAST examination, and the other six patients entered the ICU for urgent care, FAST findings, and follow-up. US findings were correlated with patients' clinical data.
Results
US is very useful in the follow-up of patients with minor IAI and it decreases the use of computed tomography. However, ultrasound is operator dependent and could overlook lacerations of solid organs and gastrointestinal injuries. Therefore, contrast-enhanced computed tomography is still considered the gold standard in the evaluation of the exact site and the degree of IAI.
Conclusion
We concluded that ultrasound is considered the best modality in the initial evaluation of patients with BAT. However, repeated ultrasound in patients of BAT increases the sensitivity of ultrasound for causing intra-abdominal bleeding to 100%.

Keywords: abdominal, blunt, trauma, ultrasonography


How to cite this article:
Alwakil AM, Habib RM, Abdelmonem S. Role of ultrasonography in blunt abdominal trauma. Menoufia Med J 2017;30:876-9

How to cite this URL:
Alwakil AM, Habib RM, Abdelmonem S. Role of ultrasonography in blunt abdominal trauma. Menoufia Med J [serial online] 2017 [cited 2019 Nov 15];30:876-9. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/876/218269


  Introduction Top


Trauma is the most common cause of mortality in the age group between 1 and 45 years. Blunt abdominal trauma (BAT) is common, and the prevalence of intra-abdominal injury (IAI) following BAT has been reported to be as high as 12–15%. The most common mechanisms resulting in BAT were motor vehicle collisions (73%), motorcycle collisions (7%), auto–pedestrian collisions (6%), and falls (6%) [1],[2].

Rapid diagnosis and treatment of abdominal injury are important steps to prevent deaths in patients with BAT. In BAT, rapid determination of which patients should require emergent laparotomy is crucial for life saving, especially for those with unstable hemodynamics. On the contrary, avoidance of unnecessary laparotomy, which is an invasive procedure with inherent complications, is also important [2],[3].

Currently, ultrasonography (US) is the primary method of screening patients with BAT worldwide. Ultrasonograms can demonstrate a number of traumatic lesions, such as hematomas, contusions, bilomas, and hemoperitoneum [2].

This study examines the role of ultrasound focused assessment with sonography in trauma (FAST), which is used at the time of presentation and is repeated after 12–24 h, in the early diagnosis of IAI following BAT and follow-up US in patients with IAI for early diagnosis of late complications.


  Patients and Methods Top


This i s a prospective study of 50 patients presented to the Emergency Department of Menoufia University Hospital with BAT who underwent US and FAST examinations at the time of presentation (Toshiba ultrasound device with 3.75 MHz convex transducer; Toshiba, CA, USA) and were followed up with US after 12–24 h (GE ultrasound device with 4.0 MHz convex transducer; GE, Guangdong, China). All except 12 patients were hemodynamically stable; six patients had severe intra-abdominal hemorrhage and entered the operation theater urgently after FAST examination and the other six patients entered the ICU for urgent care, FAST findings, and follow-up. US findings were correlated with patients.

Full clinical history and examination included the following: age and sex of the patients, type of the trauma (car accidents, motorcycles accidents, falling from height, or falling on stairs), evaluation of vital signs (pulse and blood pressure), and abdominal examination for associated skin contusion or hematoma.

The radiological signs looked for are as follows: fluid collection within the different pouches and its amount (mild, moderate, or marked); any internal organ injury and its degree and whether it is an isolated organ injury or a multiorgan injury; signs of active bleeding (extravasation of contrast material); vascular injuries; and retroperitoneal hematoma.

Statistical analysis

All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for Windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for Windows (MedCalc Software bvba, Ostend, Belgium).

Quantitative data were expressed as mean ± SD and median (range), and qualitative data were expressed as absolute frequencies (N) and relative frequencies (%). Continuous data were checked for normality using the Shapiro–Wilk test. Mann–Whitney U-test was used to compare two groups of non-normally distributed data. One-way analysis of variance test was used to compare more than two groups of normally distributed data, whereas Kruskal–Wallis H-test was used for non-normally distributed data. Percentages of categorical variables were compared using c2-test. McNemar test was used for paired categorical data.


  Results Top


This study was conducted on 50 patients (36 male and 14 female) with different age groups who presented with BAT and had positive FAST finding.

Car accident represents the most common cause of 70% and was more common among male patients of 48%. The male to female ratio was 2.5:1. The most affected individuals are those in the 2–10-year-old age group.

The liver was the most common injured organ, representing 41.7%, followed by the spleen 31.3%, the kidney 16.7%, and the peritoneum 8.3%, whereas the pancreas was the least common one, representing only 2.1% of all our patients.

The liver was the most common injured organ in children and young adults, representing 65% of patients with liver injury, whereas the spleen was the most common injured organ in adults, representing 53.7% of patients with splenic injuries [Table 1].
Table 1: The relation between the injured organ and age

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Grade II hepatic injury was the most common, representing 65% of patients with hepatic injury [Table 2].
Table 2: Number and percentage of patients according to grades of liver injury

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Also grade II splenic injury was the most common, representing 73% of patients with splenic injury. Both grades I and II renal injuries were the most common, each representing 37.5%.

Overall, 94% (47 patients) of our patients had isolated organ injury, whereas only 6% (three patients) had multiorgan (combined) injuries [Figure 1] and [Figure 2].
Figure 1: The spleen shows a hyperechoic area related to the anterior surface of the spleen measuring 1 cm × 0.5 cm.

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Figure 2: The right lobe of the liver shows a subcapsular hypoechoic area measuring 2 cm × 1 cm in its maximum diameter (hematoma), lower echogenicity compared by focused assessment with sonography in trauma examination, and decreased free fluid at Morison's pouch.

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  Discussion Top


Trauma is the most common cause of mortality between the age of 1 and 45 years. BAT is common, and the prevalence of IAI following BAT has been reported to be as high as 12–15%. The most common mechanisms resulting in BAT were motor vehicle collisions (73%), motorcycle collisions (7%), auto–pedestrian collisions (6%), and falls (6%) [1],[2].

Rapid diagnosis and treatment of abdominal injury are important steps to prevent death in patients with BAT. In BAT, rapid determination of which patients require emergency laparotomy is crucial for life saving, especially for those with unstable hemodynamics. On the contrary, avoidance of unnecessary laparotomy, which is an invasive procedure with inherent complications, is also important [2],[3].

Our study included 50 patients with different age groups. All 50 patients presented with BAT and showed positive FAST findings.

In our study, 36 patients were male and 14 were female. The age ranged between 2 and 70 years.

In the study of 327 patients with BAT examined during 1999 by Pai [4] 52 (15.9%) patients had ultrasound-detectable intra-abdominal lesions, which included 37 male and 15 female patients. The age ranged between 2 and 83 years. Regarding the cause of trauma, he found that car accidents represented 79% of patients, followed by accidental falling (13%). In the current study, car accident represented the most common cause (70%), followed by motorcycle accident (14%).

This agrees with the study findings by Pai A [4] who reported that most BATs are caused by car accident (>75% of patients).

Pai A [4] had stated that the most common injured organ in BAT is the spleen. In 50% of patients, it is the only injured intraperitoneal organ.

Moreover, Chen et al. and Papadoliopoulos et al., [5],[6] reported the spleen is the most commonly injured solid abdominal organ following BAT.

However, in our study, the liver was the most commonly injured organ, representing 40% of all our patients; this is because most of our patients comprised individuals in their first decade of life.

Pai A [4] stated that the liver is the second most frequently affected intraperitoneal solid organ in adults and the first one in children.

As shown in our study, the liver was the most common injured organ in children and young adult, representing 65% of patients with liver injury, whereas the spleen was the most common injured one in adults, representing 53.7% of the patients with splenic injury.

Chen et al. and Papadoliopoulos et al., [5],[6] reported that isolated hepatic lesions are rare, and in 77–90% of patients, lesions of other organs and viscera are involved.

This was against the findings of our study, where most patients were isolated organ injuries (41.7%), and the liver was the most injured organ in our study so the hepatic lesions were nearly almost isolated.

Healy et al., and Jansen et al. [7],[8] stated that urinary tract injuries occur in 3–10% of all patients with abdominal trauma, with the kidney being the most commonly injured organ. It was seen in 80–90% of the patients.


  Conclusion Top


US is considered the best modality in the initial evaluation of patients with BAT as it is readily available, requires minimal preparation time, is not invasive, and may be performed with mobile equipment that allows greater flexibility in patient positioning. However, ultrasound examination is operator dependent, lacerations of solid organs can be overlooked, and injuries of the dome or lateral segment of the liver can be overlooked, especially in the presence of ileus or an uncooperative patient. Moreover, hepatic lacerations or hematomas may be difficult to detect, especially in the acute phase, when they are isoechoic to the normal liver. Pancreatic and gastrointestinal injures are difficult to be seen by US; however, presence of intra-abdominal fluid (positive FAST) is suggestive of IAI, and contrast-enhanced computed tomography should be performed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kendall JL, Kestler AM, Whitaker KT, Adkisson MM, Haukoos JS. Blunt abdominal trauma patients are at very low risk for intra-abdominal injury after emergency department observation. West J Emerg Med 2011; 12:496–504.  Back to cited text no. 1
    
2.
Mohammadi A, Ghasemi-rad M. Evaluation of gastrointestinal injury in blunt abdominal trauma 'FAST is not reliable': the role of repeated ultrasonography. World J Emerg Surg 2012; 7:2.  Back to cited text no. 2
    
3.
Tsui-Chi L, Fung-Hin T, Chung-Kin L. Focused abdominal sonography for trauma in the emergency department for blunt abdominal trauma. Int J Emerg Med 2008; 1:183–187.  Back to cited text no. 3
    
4.
Pai A. Spleen anatomy. Emedicine; 2012. Available from: http://emedicine.medscape.com/article/1948863- overview#aw2aab6b3. [Last accessed 2016 May].  Back to cited text no. 4
    
5.
Chen MJ, Huang MJ, Chang WH, Wang TE, Wang HY, Chu CH, et al. Ultrasonography of splenic abnormalities. World J Gastroenterol 2005; 11:4061–4066.  Back to cited text no. 5
    
6.
Papadoliopoulos I, Bourikos P, Chloptsios C, Ilias O, Moustakis E, Karanasiou V, Stamatiou K. Pancreatic injury revealed in abdominal ultrasound: a case report. Ulus Travma Acil Cerrahi Derg 2009; 15:396–398.  Back to cited text no. 6
    
7.
Healy JC, Reznek RH. Peritoneal anatomy. Br Inst Radiol 2000; 12:1–9.  Back to cited text no. 7
    
8.
Jansen JO, Yule SR, Loudon MA. Investigation of blunt abdominal trauma. BMJ 2008; 336:938–942.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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