Experience with diagnostic peritoneal lavage in blunt abdominal trauma

Fifty-one patients who had suffered blunt abdominal trauma were assessed clinically and with diagnostic peritoneal lavage. The latter has been shown to be a safe, accurate means of determining the presence or absence of haemoperitoneum. Furthermore, in patients with disturbed conscious states, the initial clinical assessment has been found to be inaccurate and the performance of diagnostic peritoneal lavage has resulted in a statistically significant increase in diagnostic accuracy (P = 0.006). However, in patients with a normal conscious state, the improvement in diagnostic accuracy achieved by the performance of diagnostic peritoneal lavage was not statistically significant. The technique of diagnostic peritoneal lavage is discussed in detail.     

Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma

Three hundred one hemodynamically stable patients with equivocal abdominal examinations following blunt abdominal trauma had a CT scan followed by DPL. Both studies were negative in 194 patients (71.6%) and positive in 51 patients (27.1%). Seven of the 51 patients (13.7%) had an additional significant injury at operation that was not seen on the CT scan. Nineteen patients had a negative CT scan, a positive DPL, and a significant injury confirmed at celiotomy. In this group of 19 patients, the CT failed to identify seven splenic, three hepatic, and three small bowel injuries. There were two complications attributed to DPL. Three patients had a false negative DPL. Diagnostic peritoneal lavage continues to be a reliable study (sensitivity--95.9%, specificity--99%, accuracy--98.2%). The CT scan is not as sensitive (sensitivity--74.3%, p less than 0.001; specificity--99.5%, accuracy--92.6%). It is concluded that selective use of both procedures is appropriate as long as one recognizes the inherent limitations of each.     

Discriminate diagnostic peritoneal lavage in blunt abdominal injuries: accuracy and hazards.

The diagnostic peritoneal lavage for hemoperitoneum in blunt abdominal injuries is a safe test, and its high accuracy reported in unselected consecutive cases, is maintained equally in the clinically equivocal patients, the very group where one is expected to relay more decisively on the results of the D.P.L.     

Diagnostic peritoneal lavage in blunt abdominal trauma.

Diagnostic peritoneal lavage is accurate and safe. It leads to fewer unnecessary laparotomies than if clinical examination alone is used and nearly eliminates deaths from undiagnosed abdominal injuries. Persons with clinical abdominal findings, shock, altered sensorium, and severe chest injuries after blunt trauma should undergo the procedure.     

Sonography versus peritoneal lavage in blunt abdominal trauma

The reliability of sonography and peritoneal lavage in assessing the need for immediate surgical intervention in blunt abdominal trauma was examined in a prospective study (n = 71). Statistical analysis revealed a sensitivity of 100% for peritoneal lavage compared to 84% for sonography; the accuracy was 99% versus 86%, the predictive value 97% vs. 89%. The statistical difference was significant (p less than 0.05). The results demonstrate that sonography cannot replace peritoneal lavage in the diagnosis of blunt abdominal trauma. The discussion of the advantages and disadvantages of both methods shows that sonography and peritoneal lavage are not competing, but rather, are complementary examinations.     

Diagnostic peritoneal lavage in blunt abdominal trauma.

A prospective study to determine the reliability of diagnostic peritoneal lavage in blunt abdominal trauma was carried on during the 11 year period January 1978 to February 1989. Abdominal injury was correctly diagnosed by peritoneal lavage in 1,275 of 1,305 patients (97.7%). In the present study the charts of these patients were reviewed. Of the 555 patients in whom peritoneal lavage was positive and who underwent laparotomy, only 396 patients had an intraabdominal injury that required operation according to our new criteria for the treatment of blunt abdominal trauma. Sixty of the 555 patients had minor injuries that were treated conservatively. The remainder had either little (n = 78) or no (n = 21) intra-abdominal damage except a small amount of free blood about 20 ml in the peritoneal cavity. Diagnostic peritoneal lavage is accurate (97.7%) in detecting free blood in the abdominal cavity. On the other hand, it results in a high percentage of unnecessary laparotomies (28.6%). Patients with blunt abdominal trauma in whom peritoneal lavage shows the presence of blood should be investigated further to reduce the number of unnecessary laparotomies.     

Effectiveness of peritoneal lavage in blunt abdominal trauma.

To analyze the effectiveness of peritoneal lavage and to define its limitations in the evaluation of patients who have sustained blunt abdominal trauma, a prospective study of 500 such patients was undertaken by the Trauma Service at the Naval Hospital, San Diego. Utilizing a qualitative colorometric method to evaluate the degree of hemoperitoneum, patients could rapidly be divided into three clinical groups: strongly positive, weakly positive, and negative. Using this method, patients with a strongly positive peritoneal lavage had a 94% incidence of significant intra-abdominal injuries. In 333 patients with a negative lavage, there was no documented incidence of significant intra-abdominal injuries. Visceral angiography and abdominal echography were utilized in this group of patients to identify those with significant intra-abdominal injuries. By utilizing this approach, there were only eight unnecessary celiotomies in the total group of 500 patients. It is concluded, therefore, that peritoneal lavage is a safe, rapid, and effective means of evaluating patients who have sustained blunt abdominal trauma.     

Computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. Their combined role

We reviewed medical records and films of all 196 trauma patients who underwent computed tomography (CT) between June 1982 and October 1986 to see whether CT achieved the level of accuracy attributed to it, whether diagnostic peritoneal lavage (DPL) performed in conjunction with CT was a useful diagnostic test for blunt abdominal trauma, and whether laparotomy was mandatory when pelvic fluid collections were seen by CT after blunt trauma. A total of 36 patients underwent DPL, 29 before and seven after CT. There were seven false-negative CTs that were clinically significant. Diagnostic peritoneal lavage was positive in three patients who had false-negative CTs. Although overall accuracy was excellent, CT was not reliable in detecting bowel injury. Diagnostic peritoneal lavage was helpful in detecting injuries missed by CT. Most stable patients with moderate or large intraperitoneal fluid collections on CT accompanying solid viscus injury were treated successfully without laparotomy.     

Analysis of peritoneal lavage parameters in blunt abdominal trauma

Peritoneal lavage is the most valuable diagnostic modality presently available for the evaluation of patients with blunt abdominal trauma. A retrospective review of 523 patients who underwent open peritoneal lavage for blunt abdominal trauma over a 3 1/2-year period revealed serious intra-abdominal pathology in 83% of patients undergoing laparotomy with RBC lavage counts in the range of 20,000 to 100,000 cells/mm3, a level considered by many authors to be negative or indeterminate. Two patients with isolated small bowel perforations had an elevated amylase level as the only measured abnormality. The data indicate that the standard guidelines for RBC positivity (positive count greater than 100,000 cells/mm3 and indeterminate count 50,000 to 100,000 cells/mm3) result in missed intraperitoneal injuries in a large percentage of patients and therefore require reevaluation. Lavage amylase determinations, previously stated to be costly and of insignificant yield, should be performed on patients whose lavage would otherwise be considered negative by RBC and WBC counts.     

诊断性腹腔灌洗及CT和B超对钝性腹部创伤诊断的比较

目的 比较诊断性腹腔灌洗（DPL），CT和B超对钝性腹部创伤诊断的准确性。方法 前瞻性分析61例血流动力学稳定的钝性腹部创伤病例，病人入院后首先行B超和CT检查，之后再完成DPL。如3项检查中有1项阳性则剖腹探查，并将手术发现与检查结果作比较。结果 DPL，CT，B超对钝性腹部创伤诊断的敏感性，特异性，准确性分别为97．4％，81．7％，91．8％，97．3％，91．3％，95．1％及92．3％，90．9％，91．5％。3项检查对钝性腹部创伤诊断的准确性相似，但B超与DPL和CT相比具有迅速，方便，重复性好，可在床旁进行等优点。结论 在对钝性腹部创伤的诊断中B超可以取代DPL，CT可作为补充诊断手段。     

Diagnostic peritoneal lavage in blunt and penetrating abdominal trauma.

Peritoneal lavage as a diagnostic aid is described in a small series which includes both blunt and penetrating abdominal trauma. Its value for blunt injuries has been confirmed, and it is recommended for penetrating injuries, when the diagnosis of visceral injury is in doubt.     

Critical analysis of open peritoneal lavage in blunt abdominal trauma

Using the generally accepted paracentesis and lavage criteria for laparotomy for patients with blunt abdominal trauma, we found an accuracy rate of 97 percent but a nontherapeutic laparotomy rate of 27 percent. The 17 percent true false-positive rate of paracentesis and lavage is much higher than has been previously appreciated.     

Variation among trainee surgeons in interpreting diagnostic peritoneal lavage fluid in blunt abdominal trauma.

Diagnostic peritoneal lavage is useful in selected patients who have sustained blunt abdominal trauma. The way in which 50 trainee surgeons (37 registrars and 13 senior registrars) perform and interpret diagnostic peritoneal lavage was investigated in this study by a simple questionnaire followed by assessment of simulated lavage fluid. This exposed misconceptions about interpretation of diagnostic peritoneal lavage fluid and a reliance upon visual assessment. Assessment of the simulated lavage fluid revealed a wide range of thresholds for a positive result (2460-48,700 red blood cells/mm3), although 49 surgeons (98%) had lower thresholds than that generally recommended. Senior registrars had significantly higher thresholds than registrars, implying a learning curve involving unnecessary laparotomies. In order to avoid this situation and to detect injuries that might otherwise be missed, trainee surgeons are recommended to perform cell count analysis routinely on diagnostic peritoneal lavage fluid.     

The complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma

To determine the roles of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (CT) in the evaluation of blunt abdominal trauma, we compared our results in the eras before and after the advent of abdominal CT. In the pre-CT era 1977 to 1980 (group 1; 365 patients), DPL was the diagnostic procedure of choice. In the CT era 1983 to 1986 (group 2; 282 patients), DPL was used for unstable, polytraumatized patients, and CT was reserved for stable patients. The rate of delayed recognition of documented visceral injury (7%) was similar for groups 1 and 2. Celiotomy was nontherapeutic in 21 (14%) patients in group 1 and in 5 (5%) in group 2 (p less than 0.02). Despite immediate availability of abdominal CT, clinical examination alone or in combination with DPL was the diagnostic procedure of choice in 41% of those with blunt abdominal trauma in group 2. The complementary use of abdominal CT and DPL in those with blunt abdominal trauma decreased the rate of nontherapeutic celiotomy, did not result in a significant increase in missed injuries, and allowed identification of candidates for nonoperative management of solid organ injury.