Small bowel perforation: is urgent surgery necessary?

BACKGROUND: Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagnosis is also debatable. The purposes of this study were to evaluate the relationship between treatment delay and outcome of small bowel perforation after blunt abdominal trauma and to determine the best assessment plan for the diagnosis of this injury. METHODS: One hundred eleven consecutive patients with small bowel perforations caused by blunt abdominal trauma were retrospectively reviewed. The patients were divided into four groups according to the time interval between injury and surgery. Hospital stay, time to resume oral intake, and mortality and morbidity rates were compared between groups. Physical signs, laboratory and computed tomographic findings, and the results of diagnostic peritoneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation. RESULTS: Delay in surgery for more than 24 hours did not significantly increase the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increased significantly when surgery was delayed for more than 24 hours. Abdominal tenderness was a common finding, but it was not specific for bowel perforation. Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage. By using cell count ratio in diagnostic peritoneal lavage and/or increased lavage amylase activity, presence of particulate matter and/or bacteria in the lavage fluid, all patients with intraperitoneal bowel perforation were diagnosed accurately before operation. CONCLUSION: Small bowel perforation has low mortality and complication rates if it is treated earlier than 24 hours after injury. The principle of "rushing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of treatment for the small bowel perforation should be lower than the limb-threatening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a specially designed positive criterion is applied.     

Computerized tomography as an indicator of isolated mesenteric injury. A comparison with peritoneal lavage

This study evaluated 18 patients with blunt abdominal trauma who suffered isolated mesenteric injuries, diagnosed at exploratory laparotomy. Thirteen had diagnostic peritoneal lavage (PL) as their initial diagnostic study, and five had computed tomography (CT). All patients who had positive PL were explored emergently, undergoing repair of mesenteric injuries. Three of the five patients with CT as initial studies had delayed recognition of their injuries due to incorrect initial interpretation of the scan in two, and a false negative scan in one. Two of these patients developed intestinal infarction and required bowel resection. There were no complications in the PL group related to surgery; morbidity was greater in those undergoing CT. We conclude that early laparotomy and repair of significant mesenteric injuries is necessary to reduce morbidity, and that PL is a more sensitive indicator of this injury than CT.     

Isolated mesenteric injury due to blunt abdominal trauma

Isolated injuries of the small bowel mesetery or mesocolon with subsequent bowel infarction due to blunt abdominal trauma are rare. Two cases are described: 1 involving the mesentery to the terminal ileum and 1 involving the transverse mesocolon and middle colic artery, both with bowel infarction. The modes of clinical presentation and management of patients with injuries to the mesentery, mesocolon and mesenteric vessels following blunt trauma are described.     

The problem of the closed abdominal injury in polytrauma patients]

The histories of 66 patients with blunt abdominal trauma requiring surgery in the period from 1985 to 1989 were analysed. The patients were divided into three groups on the basis of the other injuries present. Group I, isolated blunt abdominal trauma and blunt abdominal trauma with slight concomitant injuries (18 patients, ISS 17.17 +/- 1.40); group II, blunt abdominal trauma with severe concomitant injuries but without craniocerebral trauma (23 patients, ISS 29.34 +/- 1.45); and group III, blunt abdominal trauma with severe concomitant injuries and an additional craniocerebral trauma (25 patients, ISS 31.08 +/- 1.27, GCS: 10.04 +/- 0.88). Initially, the diagnosis was made in 23 cases by means of diagnostic peritoneal lavage and in 43 cases by means of sonography. The subsequent laparotomy revealed the ultrasound findings to have been false-positive in 3 cases. No false-negative ultrasound findings were demonstrated at all. Peritoneal lavage, on the other hand, was found to have yielded false-negative and false-positive findings in 2 cases each. Counting from the time of admission, the time up to diagnosis of the intra-abdominal injury was 85 +/- 14.3 min in group I, 82 +/- 9.9 min in group II, and 86 +/- 12.9 min in group III. Thus, the presence of severe additional injuries did not lead to any significant delay in the diagnosis of blunt abdominal injury requiring surgery. The total mortality rate was 18.18% (group I, 11.1%; group II, 21.7%; group III, 20.0%). Six patients died in the acute phase and a further six patients during their stay on the intensive care ward.     

Blunt intestinal trauma. A modern-day review.

During the 5-year period from January 1978 through December 1982, 196 patients with blunt trauma to the small bowel, colon, or mesentery were treated at the Maryland Institute for Emergency Medical Services Systems (MIEMSS) Shock Trauma Center. More than 80% of these patients were the victims of motor vehicle accidents and therefore commonly had multisystem injuries. Sixty of these patients suffered 83 major injuries in the form of perforation or mesenteric injury resulting in ischemic bowel. This group accounted for 6.9% of the 870 patients who had celiotomy for blunt trauma during this period. Several significant observations were made. All injuries, except one, were diagnosed by peritoneal lavage. Only two duodenal injuries were present. Perforations involving the jejunum and ileum were distributed throughout the entire length of the small bowel. Colon injuries comprised one-fourth of the major injuries, with most occurring in the ascending and sigmoid colon. There were 16 deaths, 6 of which occurred as a result of complications from the bowel injury.     

The diagnosis of gastrointestinal tract injuries resulting from blunt trauma.

BACKGROUND: This review studies the efficacy of the methods of assessment of the abdomen in blunt trauma for the detection of gastrointestinal tract injuries (GITI). METHODS: MEDLINE searches of English language publications on the subjects of diagnostic peritoneal lavage, abdominal computed tomography (CT) in blunt trauma and gastrointestinal tract injuries between 1980 and 1998 were used to identify relevant material. Earlier publications were identified from reference lists. The methodology, data and conclusions of all studies were examined in detail. The contemporary roles of clinical assessment, diagnostic peritoneal lavage, CT and other diagnostic modalities in detection of significant GITI were determined based on the best available evidence. CONCLUSIONS: The most accurate and safest methods of assessment of the abdomen in haemodynamically unstable patients with suspected abdominal injuries following blunt trauma are immediate laparotomy or diagnostic peritoneal lavage (DPL). The goal of assessment of the abdomen in stable patients is to accurately define the site and extent of intra-abdominal injury, in order that further management may be tailored to the specific injuries. The most recent evidence suggests that CT of the abdomen fulfils these criteria better than the other modalities of assessment available. The risk of overlooking a significant GITI on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking and bowel dilatation are taken as evidence of GITI. When scan quality is suboptimal or expert interpretation is unavailable, DPL is recommended. Fully cooperative patients with negligible abdominal signs can be safely observed clinically.     

THE DIAGNOSIS OF GASTROINTESTINAL TRACT INJURIES RESULTING FROM BLUNT TRAUMA

Background : This review studies the efficacy of the methods of assessment of the abdomen in blunt trauma for the detection of gastrointestinal tract injuries (GITI). Methods : MEDLINE searches of English language publications on the subjects of diagnostic peritoneal lavage, abdominal computed tomography (CT) in blunt trauma and gastrointestinal tract injuries between 1980 and 1998 were used to identify relevant material. Earlier publications were identified from reference lists. The methodology, data and conclusions of all studies were examined in detail. The contemporary roles of clinical assessment, diagnostic peritoneal lavage, CT and other diagnostic modalities in detection of significant GITI were determined based on the best available evidence. Conclusions : The most accurate and safest methods of assessment of the abdomen in haemodynamically unstable patients with suspected abdominal injuries following blunt trauma are immediate laparotomy or diagnostic peritoneal lavage (DPL). The goal of assessment of the abdomen in stable patients is to accurately define the site and extent of intra-abdominal injury, in order that further management may be tailored to the specific injuries. The most recent evidence suggests that CT of the abdomen fulfils these criteria better than the other modalities of assessment available. The risk of overlooking a significant GITI on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking and bowel dilatation are taken as evidence of GITI. When scan quality is suboptimal or expert interpretation is unavailable, DPL is recommended. Fully cooperative patients with negligible abdominal signs can be safely observed clinically.     

Presentation of blunt small intestinal and mesenteric injuries

During the 10 year period from 1988 to 1997, 64 patients with blunt small bowel and mesenteric injuries were treated at two trauma centres. The majority (52 cases) were victims of motor vehicle accidents, and 54% of them wore seat belts at the time of the accident. There were 22 small bowel injuries (17 full-thickness and 5 seromuscular) and 42 mesenteric injuries (7 with and 35 without a devascularised bowel segment). Shock on admission was present in 34% of the patients and generalised abdominal tenderness in 75%. Diagnostic peritoneal lavage was positive for blood in 25 out of 36 cases in which it was performed (69%), and positive for bowel content in 4/6 patients (67%) with full-thickness bowel perforations or transactions. Emergency room ultrasound was positive for blood in 13/25 cases (52%), and CT scan in 7/17 (41%). It is concluded that blunt small bowel and mesenteric injuries including patients with perforated or ischaemic bowel are difficult to diagnose using currently available diagnostic tools, and require a low threshold for exploration based on clinical suspicion in order to reduce the complications following delayed treatment of these injuries.     

Mesenteric injuries after blunt abdominal trauma: delay in diagnosis and increased morbidity

Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.     

Injuries of the small and large intestine in the traumatized abdomen

Between 1973 and 1989 a total of 388 patients underwent laparotomy because of abdominal trauma. In 98 cases, injuries of the small bowel, the colon or the mesentery were found. The injuries were caused by motor vehicle accidents in 55 patients; 12 had gunshot or stab wounds and 12 committed suicide. There were 78 patients who had sustained a blunt abdominal trauma and 20 patients with a penetrating trauma. Only 21 patients had suffered a solitary injury of the gastrointestinal tract. In 41 patients there were also lesions to other intraabdominal organs, in 11 patients, thoracic injuries and in 24 patients, a craniocerebral trauma. Combined injuries of skull, thorax and abdomen were present in 24 patients. Neither ultrasound nor peritoneal lavage allows reliable prediction of injuries of the gastrointestinal tract. In 51 cases a defect of the mesentery or serosa was repaired. In 54 patients there was a rupture of the small or large intestine: in 20 of these cases primary repair without resection was performed and in 34, resection and anastomosis. Ileostomy or colostomy was done in only 8 patients. An anastomotic leak developed in 2 patients. Lethality is correlated to the extent of concomitant injuries. Solitary injury of the small bowel or colon was followed by lethality of only 4.1%, increasing to 50% in patients with combined injuries of skull, thorax and abdomen.     

Selective peritoneal lavage in the management of comatose blunt trauma patients

Comatose blunt trauma patients undergo diagnostic peritoneal lavage to aid in the management of severe injuries. In deference to routine performance of lavage, patients felt to be a risk for abdominal injury were prospectively studied by using selective criteria for lavage. One hundred consecutive comatose blunt trauma patients were studied; five underwent urgent celiotomy for refractory hypotension. Five criteria for lavage were: history of postinjury hypotension, abdominal physical findings suggestive of underlying abdominal injuries, evidence of fracture of the bones of the trunk and/or femur, blunt trauma of unknown etiology, and operative general anesthesia required for nonabdominal injuries. Fifty-five patients satisfied at least one of the above criteria and underwent peritoneal lavage. Forty patients not satisfying the criteria were observed without peritoneal lavage, as it was felt they had a decreased probability of serious abdominal injury. One of these patients had a minor liver laceration found at the time of autopsy following his death from severe head injury. None of the other patients had evidence of intra-abdominal injury by autopsy or subsequent clinical course. Utilizing the selective criteria, none of the 100 consecutive blunt trauma patients had major delay in abdominal diagnosis or missed significant abdominal pathology defined by operation, clinical course, or autopsy. Routine peritoneal lavage in all comatose blunt trauma patients may subject the patient to unnecessary risk, waste valuable time, increase the cost of care, and alter subsequent diagnostic procedures. Based on this small study, it appears that comatose blunt trauma victims not fulfilling the criteria may be effectively evaluated without the use of peritoneal lavage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Usefulness of Multidetector Computed Tomography for the Initial Assessment of Blunt Abdominal Trauma Patients

Background The prompt detection and accurate localization of abdominal injuries are difficult. Some diagnostic modalities, including laboratory tests, ultrasound, and diagnostic peritoneal lavage (DPL) were used to evaluate patients with blunt abdominal trauma, with various advantages and pitfalls. We aimed to evaluate the risk and benefit of using multidetector computed tomography (MDCT) as an initial assessment tool for proper diagnosis and treatment planning of patients with blunt abdominal trauma. Methods Two hundred fifty-two patients with blunt abdominal trauma were prospectively enrolled. Multidetector computed tomography was performed during resuscitation. The risk and benefit of using MDCT in the diagnosis and planning of treatment were analyzed. Results The time required for a MDCT examination averaged 10.2 minutes. Of the studies done, 224 revealed abdominal injuries. Of those, 34 were performed in patients with unstable hemodynamic status without adverse effect. Prompt diagnosis and proper treatment were given according to the MDCT findings. A total of 43 (17.1%) MDCTs showed contrast extravasation. Active bleeding was confirmed in all and treated with transarterial embolization (30) or surgery (13). Another 58 patients sustained bowel, mesenteric, or pancreatic injuries (BMPI) necessitating laparotomy. The sensitivity, specificity, and accuracy of MDCT in identifying patients with active bleeding or BMPI were all 100%. Conclusions Multidetector computed tomography was useful as a second line initial assessment tool to identify injuries and determine treatment planning in blunt abdominal trauma patients. No increased risk was found if the facility is readily available, the protocol is well designed, and the patient is well prepared.     

Large animal-related abdominal injuries

BACKGROUND: This study investigated injuries to the abdominal area of the body caused by large animals, as well as the management of this problem. METHODS: All the patients with large animal-related abdominal injuries over a 10-year period were identified retrospectively through the general surgery registrations. RESULTS: Overall, 113 patients were hospitalized after large animal encounters during the 10-year study period, 33 (30%) of which had large animal-related abdominal injuries. These patients comprised 10 women (30%) and 23 men (70%) with a mean age of 56 +/- 14 years. Of the 33 patients, 31 (93.9%) sustained blunt injuries and 2 (6.1%) experienced penetrating abdominal trauma. The mean Injury Severity Score was 12.7 +/- 4.0, and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 10.6 +/- 3.2. The mean intensive care unit stay was 0.8 +/- 2.2 days, and the total hospital length of stay was 7.3 +/- 5.6 days. Whereas 12 patients (36.4%) were managed nonoperatively, 21 patients (63.6%) required surgery. Laparotomy showed injuries to the jejunum in three patients (9.1%), to the ileum in 13 patients (39.4%), to the ileal mesenterium in 1 patient (3%), to the liver in 4 patients (12.1%), and to the spleen in 2 patients (6.1%). One patient died of myocardial infarction on the second day after admission. CONCLUSIONS: Large animal-related injuries to the abdominal area can be serious. Immediate transportation and early diagnosis of abdominal insults are important because of the frequencies of small bowel and mesenteric injuries, which are difficult to diagnose using currently available diagnostic tools.     

Helical computed tomography of bowel and mesenteric injuries

BACKGROUND: The role of computed tomography in diagnosing hollow viscus injury after blunt abdominal trauma remains controversial, with previous studies reporting both high accuracy and poor results. This study was performed to determine the diagnostic accuracy of helical computed tomography in detecting bowel and mesenteric injuries after blunt abdominal trauma in a large cohort of patients. METHODS: One hundred fifty patients were admitted to our Level I trauma center over a 4-year period with computed tomographic (CT) scan or surgical diagnosis of bowel or mesenteric injury. CT scan findings were retrospectively graded as negative, nonsurgical, or surgical bowel or mesenteric injury. The CT scan diagnosis was then compared with surgical findings, which were also graded as negative, nonsurgical, or surgical. RESULTS: Computed tomography had an overall sensitivity of 94% in detecting bowel injury and 96% in detecting mesenteric injury. Surgical bowel cases were correctly differentiated in 64 of 74 cases (86%), and surgical mesenteric cases were correctly differentiated from nonsurgical in 57 of 76 cases (75%). CONCLUSION: Helical CT scanning is very accurate in detecting bowel and mesenteric injuries, as well as in determining the need for surgical exploration in bowel injuries. However, it is less accurate in predicting the need for surgical exploration in mesenteric injuries alone.     

Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries

Twenty-four patients with signs on computed tomography (CT) of mesenteric or intestinal injury were treated over a 5-year period (1980-1984). All patients were the victims of blunt abdominal trauma. Nine patients with CT evidence of mesenteric or bowel hematomas were observed without adverse outcome. Fifteen were operatively explored, with 14 having injuries similar to the findings on the preoperative CT scans. In the group that had surgery, either thickened bowel or free intraperitoneal fluid (blood or less dense fluid) or both were present in all but one patient. Extraluminal air (three cases) or Gastrografin (Squibb) (one case) were absolute indications for surgery, as were bowel wall or mesenteric hematomas accompanied by substantial amounts of intraperitoneal fluid. The patient's history, physical examination, and initial laboratory values are important in proper selection of patients for CT evaluation. We feel that CT appears to offer certain definite advantages over peritoneal lavage in evaluation of bowel and mesenteric injuries and can reliably help to distinguish the injuries that require surgical repair from those that can be safely monitored and observed.     

Small bowell perforation and mesentery injury after an unusual blunt abdominal trauma–Case report

IntroductionIn blunt abdominal trauma, lesions of the small bowell and mesentery are often underdiagnosed; although unusual, they represent the third most injured organ, with increasing morbidity and mortality.Presentation of caseThe authors present the case of a 68 years old male, admitted to the emergency department after being hit by a bale of straw, weighing around 300 kg, in the abdomen. After successful ressuscitation, a CT scan was performed, suggesting hemoperitoneum because of vascular lesion of the right colon bleeding. An exploratory laparotomy was performed, confirming the presence of blood in the abdominal cavity and identifying jejunal perforation, an apparently innocent hematoma of the small bowel mesentery (beside the bowel wall) distally to the first lesion and a laceration of the sigmoid serosa; a segmental jejunal resection and suture of the colon serosa were performed. In the early post-operative period, an enteric discharge was noticed, mandating surgical reexploration; a previously unnoticed bowel perforation, in the mesenteric border where the hematoma was identified, justified an additional enterectomy, after what the patients recovery progressed uneventfully.DiscussionIn this case, a sudden increase in abdominal pressure could explain that missed rupture of the mesenteric border of the jejunum, also causing the mesenteric hematoma, or, in spite of that, a state of low perfusion could have lead to total wall ischemia of an already irrigation compromised segment.Only noted after surgical exploration, despite prior evaluation with a computed tomography. Small bowell and mesenteric injuries are potentially missed due to decreased exploratory laparotomies for blunt abdominal trauma.ConclusionAlthough uncommon, small bowel and mesenteric injuries are associated with high morbidity and mortality. High clinical suspicion is essential for an early diagnosis     

Pneumoperitoneum in polytraumatized patients without perforated hollow viscera

Bowel and mesenteric injuries from blunt abdominal trauma are infrequent and difficult to diagnose. A finding of pneumoperitoneum on computed tomography is useful, although not specific. In associated blunt chest trauma gas can reach the peritoneal cavity through congenital or post-traumatic diaphragmatic interruptions. Two cases of pneumoperitoneum following associated blunt chest and abdominal trauma are reported. In both patients laparotomy did not show bowel perforation and conservative treatment could have been provided.     

Leukocytosis and free fluid are important indicators of isolated intestinal injury after blunt trauma

BACKGROUND: The detection of isolated intestinal injuries after blunt trauma can be difficult because of subtle signs and symptoms, often leading to delayed diagnosis. We hypothesized that specific clinical indicators could be identified to assist in the diagnosis of these injuries. METHODS: Medical records of all patients with such injuries from 1988 to 1996 were reviewed. The patients were stratified into those operated on within 6 hours of presentation (apparent injury) and those operated on after 6 hours (occult injury), and the data were compared. RESULTS: Forty-six patients with isolated intestinal injuries were identified. There were no differences in the rate of peritonitis or free fluid on abdominal computed tomography, blood loss, intraoperative findings, or morbidity and mortality between groups. Leukocytosis (sensitivity, 84.8%; specificity, 55.2%; p = 0.01) and free fluid on computed tomography were frequently present, however, and their significance was underappreciated in the occult injury group. CONCLUSION: After blunt abdominal trauma in patients without obvious indications for invasive evaluation of the abdomen (e.g., peritoneal lavage, laparoscopy, laparotomy), leukocytosis can indicate an intestinal injury. Additionally, unexplained free fluid on abdominal computed tomography must be aggressively evaluated.     

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.     

Computed tomographic scanning and selective laparoscopy in the diagnosis of blunt bowel injury: a prospective study

BACKGROUND: We prospectively evaluated whether computed tomographic (CT) scanning and selective laparoscopy (LP) for the diagnosis of blunt bowel injury (BBI) could prevent nontherapeutic laparotomy and delayed diagnosis. METHODS: Between April 1994 and May 2002, hemodynamically stable patients suspected of having BBI were enrolled in this study. Patients with hemodynamic instability or solid organ injuries with hemoperitoneum were excluded. All patients underwent a physical examination and contrast CT scanning at admission and once again approximately 12 hours (range, 6-24 hours) after admission. LP was performed under general anesthesia in patients who had local peritoneal signs and indirect CT signs (bowel thickening or isolated intraperitoneal fluid) or in whom abdominal pain or tenderness increased or intraperitoneal fluid increased on the repeat CT scan. The indications for a celiotomy were diffuse peritonitis, pneumoperitoneum on the abdominal CT scan, or bowel perforation visible on LP. RESULTS: During the study period, 399 of 1,074 patients admitted for blunt torso injuries were enrolled in this study. Eleven patients underwent emergency celiotomy and 11 underwent LP immediately after admission to the emergency department. One nontherapeutic laparotomy was performed among the patients who underwent celiotomy. The LPs revealed seven bowel perforations and one mesenteric laceration. After a repeat CT scan, three and seven of the patients underwent laparotomy and LP, respectively. Four bowel perforations were found by LP. The remaining 198 patients were treated conservatively, and no complications related to a delayed BBI diagnosis occurred. CONCLUSION: CT scanning and selective LP can prevent nontherapeutic laparotomy and delayed diagnosis in patients with suspected BBI.