Archives of International Surgery

ORIGINAL ARTICLE
Year
: 2013  |  Volume : 3  |  Issue : 3  |  Page : 211--215

Diagnostic efficacies of computed tomography and ultrasonography in pediatric blunt abdominal trauma


Navneet Redhu1, Saifullah Khalid1, Mohd Khalid1, Abhishek Jha1, Rajendra Singh Channa2, Kumar Gauraw2,  
1 Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Paediatric Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Correspondence Address:
Navneet Redhu
H. No. T1 Azim residency, New Sir Syed Nagar, Aligarh-202 002, Uttar Pradesh
India

Abstract

Background: Blunt abdominal trauma is a common cause of morbidity and mortality in children. The objectives of the study are to evaluate the specific patterns of organ injury in pediatric patients as illustrated by ultrasonography and computed tomographic (CT) scan and assess the role of nonoperative management in such cases depending upon the severity of injury and the organ injured. Materials and Methods: This prospective study was conducted on pediatric patients with blunt abdominal trauma that presented to the casualty of Jawaharlal Nehru Medical College over a period of 2 years. A total of 45 patients were examined. The ultrasonographic evaluation of the patients was performed and thereafter CT scan of the patients were performed within 24 h of hospital admission if on ultrasonography any evidence of intraperitoneal free fluid was detected with or without any detectable visceral organ injury. Results: Ultrasonography detected hemoperitoneum in 15 patients (51.72%) as compared to CT which detected it in 23 cases (79.31%). Spleen was the most common solid organ injured, encountered in 10 cases (34.48%) on ultrasonography and 15 cases (51.72%) on CT scan. Liver was the second most common injured organ which was demonstrated by ultrasonography in five cases (17.24%), while CT detected hepatic parenchymal injuries in nine cases (31.03%). CT was also significantly more sensitive than ultrasonography in the detection of renal injuries which were illustrated by ultrasound in only one case (3.44%), while CT showed renal injuries in three cases (10.34%). Pancreatic injuries were least common and were seen in two cases and were detected equally by ultrasound and CT scan. Conclusion: Ultrasonography is a very useful and sensitive investigation for the detection of hemoperitoneum and visceral injuries. However, CT better delineates the solid organs injuries and grades the injury as well, thus guiding the management protocol. Nonoperative management is the rule in hemodynamically stable patients in correlation with radiological and clinical scenario.



How to cite this article:
Redhu N, Khalid S, Khalid M, Jha A, Channa RS, Gauraw K. Diagnostic efficacies of computed tomography and ultrasonography in pediatric blunt abdominal trauma.Arch Int Surg 2013;3:211-215


How to cite this URL:
Redhu N, Khalid S, Khalid M, Jha A, Channa RS, Gauraw K. Diagnostic efficacies of computed tomography and ultrasonography in pediatric blunt abdominal trauma. Arch Int Surg [serial online] 2013 [cited 2022 May 18 ];3:211-215
Available from: https://www.archintsurg.org/text.asp?2013/3/3/211/129565


Full Text

 Introduction



Trauma is rampant in our society and the history of trauma is as old as history of mankind itself. [1] Children are more vulnerable to abdominal trauma as traumatic injuries are by far the most common cause of mortality in pediatric patients after the age of 1 year. [2] Prior to the advent of sophisticated radiological equipments, a large number of cases were subjected to unnecessary laparotomies as the decision regarding surgery was based upon clinical evaluation and diagnostic peritoneal lavage which was highly misleading and added further to the overall mortality and morbidity in this age group. It was found that 17%-19% of patients who underwent laparotomies for blunt abdominal trauma did not reveal any intraperitoneal injury. [3] With the ongoing advances in the field of radiology, it became substantially easy to detect, assess, and prognosticate the patients with blunt abdominal trauma. The paradigm shift in the management of blunt abdominal trauma from an unnecessary, aggressive routine operative intervention to a rather more useful, and noninvasive conservative approach is one of the starring achievements of radiology in the recent times. Advantages of nonoperative management include avoidance of unnecessary laparotomies and the associated reduced costs, mortality, and postoperative complications.

The unique anatomy and physiology of the abdomen of children contributes to the biomechanical response to trauma. The solid organs are comparatively larger in children and thus are more susceptible to injury. The intestines in children are not fully attached within the peritoneal cavity and so are more susceptible to injuries during sudden deceleration. Also, the urinary bladder extends up to the umbilicus at birth and descends progressively. As such, it is more vulnerable to injury than in adults.

Ultrasound in form of Focused Abdominal Sonography for Trauma (FAST) in combination with clinical assessment is an effective method for early diagnosis. The areas visualized in FAST include [4],[5] : Pericardium; splenorenal space; hepatorenal space; paracolic gutters, and pouch of Douglous or rectovesical pouch.

Though FAST is highly sensitive for detection of free intraperitoneal fluid, it is operator dependent and lacks specificity with high false-negative results and uncertain sensitivities. Also the grades of organ injury, upon which the standard management protocols are based, cannot be predicted with precision by it. [6],[7] Finally, ultrasound has questionable results in the diagnosis of diaphragmatic ruptures, vascular injuries, pancreatic, adrenal, and mesenteric injuries. [6],[7] Computed tomography (CT) on the contrary is highly sensitive in the detection of solid organ and mesenteric injuries, but has its own drawbacks regarding the radiation exposure and its inability to detect early bowel and pancreatic injuries. [8] So, we undertook this study to evaluate the roles of CT and ultrasound in pediatric abdominal trauma correlating the radiological findings with management of the patients.

 Materials and Methods



This prospective observational study was conducted in the department of radiodiagnosis and department of surgery. Pediatric patients with blunt abdominal trauma presenting to the casualty of Jawaharlal Nehru Medical College over a period of 2 years, between December 2008 and November 2010 were included. A total of 45 patients were examined. The ultrasonographic evaluation of the patients was performed with Adara sonoline-500 (Siemens) with 3.5 MHz convex array probe and 8 MHz linear array probe. Thereafter, CT scans of the patients were performed within 24 h of hospital admission if on ultrasonography any evidence of intraperitoneal free fluid was detected with or without any detectable visceral organ injury. Siemens single slice CT scan model SOMATOM balance was used for scanning. American association for the Surgery of Trauma Organ Injury Severity was used for the classification of splenic, hepatic, and renal injuries, while CT grading of pancreatic injury proposed by Moore et al., was used for assessing pancreatic injuries. [8] Following admission and resuscitation stable patients were evaluated with ultrasound and CT scan. The findings of these investigations were used to select patients that required surgical intervention.

Inclusion criteria

All patients less than 12 years of age with history of blunt abdominal trauma.Hemodynamically stable patients requiring <40 mL/kg of fluid replacement for initial resuscitation.

Exclusion criteria:

Children above 12 years.Patients with penetrating injury, burns, or other types of injury.

 Results



Majority of the patients were between 6 and 9 years old accounting for 14 patients (35%) with mean age of 8.2 ± 1.7 years. Out of the 40 patients included in the study, 26 (65%) were males, while 14 (35%) were females. The most common cause of injuries was road traffic accidents accounting for 24 cases (60%) [Table 1]. Among the solid organs injured, spleen was the commonest [Figure 1] and was injured in 15 cases (37.5%), followed by liver [Figure 2] in 9 cases (22.5%) while renal [Figure 3] and pancreatic injuries were seen in three and two patients, respectively. The overall sensitivity of ultrasound in the detection of solid organ injuries [Figure 4] was 62.06% compared to CT, where the diagnostic sensitivity was 100%. In all 29 patients, ultrasound was able to detect hemoperitoneum having sensitivity as high as 100%, similar to that of CT. A total of 11 patients encountered bowel injuries out of which isolated bowel injury was seen in 8 cases, while associated mesenteric injuries were seen in 3 cases. Out of these 11 cases, on laparotomy jejunal perforation was detected in 7 cases, while ileal perforation was seen in 4 cases. These patients underwent ultrasound examination which detected free fluid in all cases. However being hemodynamically unstable, they were not taken up for CT scan. The diagnostic efficacies of ultrasound and CT in the detection of visceral organ injuries are shown in [Table 2].{Table 1}{Table 2}{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Overall, 24 (60%) cases and 82.75% of the cases of solid organ injury were managed conservatively. In these patients, hemoperitoneum was confirmed by diagnostic peritoneal lavage. Failure of nonoperative management occurred in only five patients, out of which three sustained splenic injuries, two had liver injuries as shown in [Table 3]. Overall, one mortality was noted which was due to postoperative complications following repair of ileal injury. Thus, major surgery was avoided in a significant number of patients based upon the radiological findings. Among the isolated solid organ injuries, splenic injuries are the ones most commonly requiring operative intervention, apart from multiorgan injuries which usually require surgery.{Table 3}

 Discussion



Blunt abdominal trauma is a common health problem in the society and children are more vulnerable to it. [1] The management protocols of pediatric abdominal injuries have undergone remarkable changes in the recent times. [9] Imaging modalities like ultrasound and CT have revolutionized the detection of injuries and their management. [9] In the current study, we observed that both ultrasound and CT are highly sensitive in the detection of hemoperitoneum and organs injury with CT being slightly better in its diagnostic efficacy. This is similar to other studies reported in the literature. [5],[7],[8] The standard management has shifted from the conventional diagnostic peritoneal lavage leading to unnecessary laparotomies and postoperative morbidity and mortality. [10],[11] However, the fact that all such patients must be cautiously observed over time merits special attention as failure of nonoperative management also is seen, though infrequently. In the present study, operative intervention became necessary in five patients that were initially managed nonoperatively. However, operative intervention in these patients was not associated with increase morbidity or mortality. As such ultrasound being cheap, easily accessible, and noninvasive should be the principal initial screening investigation in all trauma patients with CT being the chief diagnostic investigation for detection of hollow viscus and mesenteric injuries as well as in the grading of solid organ injuries. [10],[11] Overall, mortality in the present study was 2.5%. One patient with bowel perforation died due to septicemia from bowel anastamotic leak. Early intervention could have saved this patient if perforation was detected earlier.

In the present study, 24 patients with solid organ injuries out of 29 solid organs injured (82.75%) were managed conservatively without operative intervention. The approach to blunt trauma involving these organs was mandatory operation in the past, but nonoperative management has been favored in hemodynamically stable patients in recent years by several authors. In the study conducted by Soham and Sweed 87% patients were treated conservatively out of 95 blunt abdominal trauma patients. [5] Several other authors also advocate conservative management of solid organ injury resulting from blunt abdominal trauma. [7],[9]

From the above observations following conclusions can be made:

The most common mode of pediatric blunt abdominal trauma is road traffic accident with the spleen being the most commonly injured intrabdominal organ.Ultrasonography is highly sensitive in the detection of hemoperitoneum and solid organ injury and so should be routinely employed as the initial investigation of choice in blunt trauma patients. However, CT can better diagnose solid organ injuries and also grade their severity, so it should be the next investigation to be performed in hemodynamically stable patients.Nonoperative management should be the standard protocol in all patients who are otherwise stable. However, patients with splenic and multiple organ injuries should be keenly observed as they may require operative intervention. Finally, nonoperative management of solid organ injuries in children with blunt abdominal trauma is safe and appropriate.

References

1Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emerg Med Clin North Am 1998;16:229.
2Sanchez JI, Paidas CN. Childhood Trauma: Now and in the new millennium. Surg Clin North Am 1999;79:1503-35.
3Nakayama DK, Copes WS, Sacco W. Differences in trauma care among pediatric and non pediatric trauma centres. J Pediatr Surg 1992; 27:427-31.
4Mutabagani KH, Coley BD, Zumberge N, Mccarthy DW, Besner GE, Caniano DA, et al. Preliminary experience with focused abdominal sonography for trauma (fast) in children: Is it useful? J Pediatr Surg 1999;34:48-54.
5Thourani VH, Pettitt BJ, Schmidt JA, Cooper WA, Rozycki GS. Validation of surgeon-performed emergency abdominal ultrasonography in pediatric trauma patients. J Pediatr Surg 1998;33:322-8.
6Ong AW, McKenney MG, McKenney KA, Brown M, Namias N, MaCloud J, et al. Predicting the need for laparotomy in pediatric trauma patients on the basis of the ultrasound score. J Trauma 2003;54:503-8.
7Retzlaff T, Hirsch W, Till H, Rolle U. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatr Surg 2010;45:912-5.
8Taº F, Ceran C, Atalar MH, Bulut S, Selbeº B, Iºik 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.
9Ozturk H, Dokucu AI, Onen A, Et Al. Nonoperative management of isolated solid organ injuries owing to blunt abdominal trauma. Eur J Pediatr Surg 2004;14:29-34.
10Graham JS, Wong AL. A review of computed tomography in the diagnosis of intestinal and mesenteric injury in pediatric blunt abdominal trauma. J Pediatr Surg 1996;31:754-6.
11Soundappan SV, Holland AJ, Fahy F, Manglick P, Lam LT, Cass DT. Transfer of pediatric trauma patients to a tertiary pediatric trauma centre: Appropriateness and timeliness. J Trauma Inj Infec Crit Care 2007;62:1229-33.