2. Newer aids in the diagnosis of blunt abdominal trauma
From the Toronto Western Hospital Reprint requests to: Dr. B. Taylor, Toronto Western Medical Building, Ste. 103, 25 Leonard Ave., Toronto, Ont. M5T 2R2
lowing: hematologic investigation, routine radiography, peritoneal lavage, scanning procedures, angiography, laparoscopy, endoscopy, ultrasonography and computer-assisted tomography. Long-standing techniques such as blood work and radiography have often been inadequate, but they will be reviewed briefly with emphasis on the few instances in which they can be valuable. Hematologic investigation
The report by Berman and associates19 in 1957 that in patients with liver and spleen injuries leukocyte counts (x 1O./ 1) averaged 24.0 and 19.0, respectively, led to enthusiasm for the specificity of this test. Although some authors corroborated this finding9 (even estimating degree of hlood loss on the basis of the leukocyte count13), most studies have found that leukocytosis is extremely variable and can follow trauma to the abdominal wall and kidneys or even to the head or limbs in the absence of serious abdominal injury.2'3'8 Although an elevated leukocyte count may suggest an abdominal injury, any conclusion about the type or presence of an intra-abdominal lesion is dangerous. The value of serum amylase determinations also is controversial. Since the clinical presentation of pancreaticoduodenal lesions often is insidious, a simple diagnostic test would be helpful. Many favour repeated serum amylase determinations to monitor the development of a pancreatic lesion;20 Freeark and associates21 even suggested that hyperamylasemia associated with upper abdominal pain is an indication for Iaparotomy. This aggressive approach results from the reported high incidence of pseudocyst formation in unexplored traumatic pancreatitis10'21 and the increased frequency of multiple organ involvement when the panqreas is injured. Determination of urinary .imylase concentration is more sensitive than that of serum amylase, and the former has therefore been advocated.4 Olsen,22 however, showed that one third of patients with hyperamylasemia had no serious injury at laparotomy, and in none was the serum amylase value the only indication of pancreatic trauma; he therefore concluded that the value of this biochemical test had been overestimated. Perhaps a middle ground between these divergent opinions is sensible; hyperamylasemia after blunt abdominal trauma may be only a suggestion of pancreatic injury, but an increasing or persistent value that supports corroborating clinical signs is undoubtedly of value. Although the hematocrit determined early is of no specific value in the assessment of blood loss into the abdo-
men, repeated determinations may detect continuing hemorrhage. These investigations, valuable as they may be in a relative way, are not helpful in making precise diagnoses in blunt trauma. Routine radiography
Plain radiographs reportedly aid assessment of the injured abdomen in only 33% of cases.2'18'23 Accuracy depends on many factors, including obesity, general condition of the patient and the technique used. Detailed reports have described the numerous radiographic findings of fluid in the abdomenM.. and of specific problems such as splenic injury and traumatic pancreatitis.28 These changes are usually subtle and inconstant. Despite their acknowledged shortcomings routine radiographs are diagnostic in a few cases of intra-abdominal injury, as follows: 1. Perforated viscus. Free air in the peritoneal cavity, whether under the diaphragm in the upright position or under the costal margin in the left lateral decubitus position, indicates a perforated viscus and is an undisputed indication for operation. Consequently it is a potentially valuable sign. even though it is present in only about 10% of cases of rupture of the small bowel27 and in a somewhat higher percentage of gastric and colonic perforations. 2. Retroperitoneal rupture. The loss of distinct psoas margins or bubbles outside the usual bowel markings strongly suggests entrapment of air from a perforated hollow viscus.27 If such is seen in the right upper quadrant, retroperitoneal duodenal rupture has to be considered. 3. Diaphragmatic rupture. Traumatic diaphragmatic hernia is often diagnosed incidentally from typical findings on plain abdominal and chest films.1 A hollow viscus in the thorax, shift of the heart and mediastinum to the right and atelectasis in the left lower lobe may all be demonstrated. Contrast studies (barium or watersoluble medium) of the gastrointestinal tract aid the assessment of blunt trauma. They may confirm the presence of an intramural hematoma of the duodenum27 or traumatic diaphragmatic hernia, localize an occult perforation of the stomach, duodenum or colon, or outline a swollen, boggy pancreas by demonstrating deviation of the stomach and duodenal loop.26 Intravenous cholangiograms occasionally help to confirm injury to the biliary tree. The importance of radiography of the genitourinary tract is discussed by Ranking elsewhere in this issue (page 617). In general, if there is any doubt of renal injury, and especially if hema-
600 CMA JOURNAL/MARCH 19, 1977/VOL. 116
tuna is evident, excretory urography should be performed in the emergency department. Paracentesis and peritoneal lavage
The four-quadrant abdominal tap was once extensively used, and the exponents of this rather crude procedure reported an accuracy of 75 to 80% *16,23 However, the false-negative rate is 10 to 50% . explaining the adage of Freeark, Love and Baker29 that "negative means nothing". In 1965 Root and colleagues30 described diagnostic peritoneal lavage, certainly the most important recent advance in investigation of abdominal trauma. They were able to demonstrate 100% accuracy in determining the presence or absence of abdominal injury in 28 patients. Little has been added to the original techniques, which are recognized and used widely. The technique is the following: After preparation of the abdomen and emptying of the bladder, an area 5.0 to 7.5 cm below the umbilicus is infiltrated with 2% lidocaine and a subumbilical incision is made in the midline. With the recti tensed (which is often not possible because of the general condition of the patient) a percutaneous peritoneal cannula is introduced into the peritoneal cavity in the direction of the pelvis. The immediate return of nonclotted fresh blood signifies appreciable intraperitoneal hemorrhage and is an indication for laparotomy. Otherwise, 1 1 of normal saline is instilled into the abdomen and left for 1 minute, after which it is evacuated by siphoning. The entire investigation takes just a few minutes, and information is immediately available. Interpretation of the nature of the effluent is critical; the finding of frank blood-staining in the returning fluid is of great importance since 88% of deaths from blunt abdominal trauma are due to hemorrhage.23 The fluid will appear salmon pink when 1 to 5 ml of blood is added to 1000 ml of saline;6'13 a further 5 to 10 ml turns the solution an intense red. Perry, DeMeules and Root31 have stated that a quantitative erythrocyte measurement of 0.1 x 1012/ml, representing a hemorrhage of 22 ml into the peritoneal cavity, is an indication for laparotomy. Interpretation of the presence of leukocytes is somewhat more qualitative; Root, Keizer and Perry32 proved that an effluent containing neutrophils demonstrates visceral injury, and added that leukocytes can be detected in the peritoneal fluid only when 2 hours have elapsed from the time of injury. Intraperitoneal intestinal content, amylase, bacteria and bile can be recognized as well, though presence of the last three are not clear operative indications but must be assessed along with other investigations.
The diagnostic peritoneal lavage is highly reliable, with a rate of falsenegative results of 0 to 2% and of false-positives, up to 4%. Peritoneal lavage, however, does have disadvantages. First, no conclusions can be drawn about the site of abdominal injury. Second, complications do occur: Thai and Shires33 reported complications in 4.5% of patients, including abdominal wall infusions, bleeding, lack of fluid return, penetration of an epiploic vein and penetration of the bladder. (To decrease the frequency of these complications Perry, DeMeules and Root31 altered their original method slightly, inserting the cannula under direct vision into the peritoneal cavity.) Third, diagnostic peritoneal lavage may be too sensitive. Certainly, a negative result indicates that there is no serious injury in the peritoneal cavity - as already stated, there are very few false-negative results. In fact, in the original series of Root and colleagues30 two patients in whom results had been negative required operation because of changing clinical signs, and no intraperitoneal injury was found. A positive result of lavage, however, often presents a dilemma. In up to 30% of patients in whom lavage was positive, with salmon-pink effluent, laparotomy revealed lesions that did not really require surgical management.. Bleeding from the abdominal wall, minor hepatic lacerations, mesenteric tears or retroperitoneal hematomas are easily detected by this diagnostic method, but the patient may be better off if these lesions are not recognized, as they usually resolve without surgical intervention. The solution to this problem is not easy and requires consideration of other diagnostic aids and an overall plan for investigation in the patient with equivocal findings. At present some surgeons3. advocate the use of this procedure in every case of suspected in.ra-abdominal trauma, while others,2 including myself, reserve it for the difficult cases. If doubt still exists after lavage, radionuclide imaging may be of value.
about 10 or 15 minutes. Splenic rupture is characterized by linear, wedge-shaped, stellate or concave defects extending inwards from the splenic margin. Evans and colleagues36 claimed that lesions as small as 1 cm can be detected, but most authors35'37 have suggested that, to be recognized, the defect must be 2 to 3 cm. Nebesar, Rabinov and Potsaid36 reported high accuracy with two falsepositive results and one false-negative scan in 32 patients with splenic injury proven at operation. These authors contended that the accuracy of the examination compares favourably with that of angiography. In another report Evans and associates36 diagnosed five cases of traumatic intrasplenic hema-
FIG. i-Value of scan of spleen in 15year-old girl who had fallen from horse 3 weeks previously and became anemic. Anterior view demonstrates defect proved at laparotomy to be large subcapsular hematoma (arrows).
toma, all confirmed at laparotomy, and had no false-positive results. Although scanning has not been used universally in blunt abdominal trauma the advantages are encouraging. The procedure is noninvasive and may be performed with virtually no risk - the patient is exposed to little radiation and the test can therefore be repeated if necessary. The results are more specific than those of diagnostic peritoneal lavage, localizing the site of injury in many instances. Also, positive scans have been reported in the presence of negative lavage;36'39 theoretically a subcapsular hematoma of the liver or spleen can be detected before rupture and therefore prior to the development of peritoneal signs or a positive lavage. The usefulness of the spleen scan in two patients with equivocal clinical presentations is demonstrated in Figs. 1 and 2. Liver trauma can also be detected by scintigraphy. As in the case of the spleen, a variety of defects such as lacerations, subcapsular hematomas and central stellate fractures have been described. As with peritoneal lavage there are certain disadvantages of scanning. The proportion of false-positive and falsenegative results remains higher than with angiography, and O'Mara, Hall and Dombroski39 and Lutzker and Freeman40 have suggested that additional views such as obliques and angulated scans can minimize the occurrence of false-positive results (Fig. 3). Although scans are noninvasive, they require time, which may not be available in treating a sick patient with multiple injuries, especially if additional views to clarify problems inherent in the technique are needed. Even though scanning usually takes little time, few
Scanning procedures
Scanning has been used mainly in cases of splenic, hepatic and renal injuries, though scattered reports of bladder, aortic and pancreatic imaging have appeared.35 The indications for these studies are the same as those for layage; for example, when the clinical assessment of a patient is compromised by any of the factors noted above and more information is needed. In hepatic and splenic scanning, technetium-99m sulfur colloid is injected intravenously and images in three planes are then developed. The entire procedure takes
FIG. 2-Value of splemc scan in 30-yearold man who had sustained punch to right side of abdomen 4 days earlier and became anemic. Splenic scan suggested fractures of spleen (arrows); ruptured spleen was later removed.
FIG. 3-False-positive splenic scan in 55year-old woman who sustained injuries to left kidney and left lower ribs. Scan apparently demonstrated fracture-like defect (arrows), but celiotomy failed to reveal injury.
CMA JOURNAL/MARCH 19, 1977/VOL. 116 601
emergency departments contain scanning equipment and the patient must be moved to the nuclear medicine laboratory. While scintigraphy localizes small defects in abdominal organs, it is not specific for the type of lesion present. Evans and . pointed out that many pre-existing lesions, particularly in the spleen (for example, celiac disease and splenic infarct) produce abnormalities similar to those after trauma. Finally, the scan, like diagnostic layage, does not give an indication of when to operate. Popovsky and associates37 reported scintigraphic diagnosis of several major hepatic injuries such as large fractures, subcapsular hematomas and central hepatic defects; five patients with such lesions were treated conservatively and all five did well. Similarly, splenic defects do not necessarily require surgical treatment. Although most surgeons would remove the spleen if a reasonable chance of a subcapsular hematoma existed, uneventful recovery has occurred with conservative management after splenic defects were demonstrated.39 Organs other than the liver and spleen have been imaged, but the practical use of these scans has not been defined. Whole-body opacification led to the diagnosis of a paraduodenal hematoma in a child,41 but the scope of this procedure is questionable. How, then, does one make the diagnosis in the patient who has equivocal signs, a negative lavage and a scan that shows a small defect in the liver or spleen? Angiography may be the answer. Angiography Indications for abdominal angiography after blunt trauma, though few, are definitely increasing as the enthusiam for this procedure grows.28'29"."42 As early as 1933.. an angiographic image produced by Thorotrast outlined hepatic injury, but dangerous side effects precluded the long-term use of this substance. Angiography may be indicated in the case of the patient whose condition is stable but in whom the findings are equivocal, and the results of other investigations are inconclusive; it may also be considered when there is unexplained blood loss, or a vascular lesion is suspected,28 or, as noted by Ranking elsewhere in this issue, in cases of renal trauma. It is a relatively safe procedure,4446 with few complications other than small groin hematomas and thromboses. Whether aortography or selective angiography is performed seems to depend on the particular radiologist's preference. Those favouring an aortic-
flush technique contend that this procedure requires less time and skill than the selective study and provides equally useful information. Angiography has several advantages: 1. Specific diagnoses can be made and information provided as to the exact nature and size of the traumatic lesion in the spleen, liver or kidneys. The detail is excellent and can be improved by intra-arterial injection of epinephrine, which constricts normal vessels, accentuating the abnormal findings.47 In the case of a ruptured spleen, subtle diagnostic signs such as extravasation, mottled parenchymal phase, arteriovenous shunts, early venous opacification, variation in vessel course, and discontinuity of splenic contour may be recognized.42 Distinct types of abnormality are also found in the injured liver.28 2. The accuracy is extremely high. There are virtually no false-negative results and very few false-positive results.42'"'45 3. Renal as well as splenic and hepatic vessels are visualized at the same time, thus providing valuable information about several organs frequently involved in a patient with multiple trauma.44'45 4. Hepatic vascular anatomy is demonstrated, aiding in hepatic lobectomy if this becomes necessary. 5. Therapeutic angiography appears to be beneficial: Margolias, Ring and Waltman48 described control of pelvic hematomas by injection of autologous clot into appropriate pelvic arteries. Despite its usefulness (Fig. 4) emergency angiography after blunt abdominal trauma is an invasive procedure that takes at least 30 to 45 minutes and often longer. Few complications, however, have been reported.
Laparoscopy Though not widely used in North America,49'50 laparoscopy has frequently been found useful in Europe. Serste and Theunis51 described 27 laparoscopies for trauma, and, though they diagnosed the type of injury in most cases, they were unable to determine the site of bleeding in many of the 12 cases of hemoperitoneum. However, Rachail, Corallo and Maurel52 accurately diagnosed 11 of 14 injuries to liver, spleen, diaphragm, pancreas and abdominal wall. Tostivint and colleagues53 had similar success in detecting intraperitoneal trauma. Many surgeons on this continent would probably question whether a procedure that requires both an incision and the instillation of several litres of carbon dioxide into the abdomen has an advantage over one requiring a slightly larger incision that permits direct examination. Even so, laparoscopy may have a place, especially if general surgeons in addition to gynecologists become adept with the specialized instrumentation, and if the improved expertise allows the procedure to be done under local anesthesia using less gas. In fact, there are reports of laparoscopy being carried out under just these latter, less traumatic, conditions. Endoscopy Although it is conceivable that upper or lower intestinal endoscopy (including retrograde pancreatography) might contribute to the abdominal assessment, no supportive evidence has developed. Ufirasonography A new investigative technique is abdominal echography. The B scanner emits high frequency sound waves that are reflected off tissues of different densities. The returning sound waves are detected by a crystal, and an image
FIG. 4-Usefulness of angiography in 43-year-old woman whose iliac crest was fractured. She was sent home after examination in emergency department. She returned next day with left upper quadrant pain and persistent hiccoughs. Although condition clinically was stable, posterior view of splenic scan (left) showed small defect (arrows). Repeat scan was equivocal but arteriogram (right) suggested normal vascular architecture (arrows). Conservative treatment and uneventful recovery followed.
602 CMA JOURNAL/MARCH 19, 1977/VOL. 116
of all interfaces in that section of the body is reconstructed. The detailed outline of intra-abdominal structures permits one to identify the liver, stomach, pancreas, bowel, kidneys, spleen and retroperitoneal area. Although few reports have appeared in recent journals one may state that critical information about intra-abdominal injuries can easily be obtained by ultrasound.54 Hom and colleagues55 gave an example of a retroperitoneal hematoma located behind the left kidney in one patient and a large hematoma situated adjacent to the spleen in another. Neither injury might have been detected by all other investigations. The possible contributions of ultrasonography are several. Unlike the other methods described it is truly noninvasive. The accuracy of the technique continues to increase as better scanners are developed. More important, all organs and masses are scanned quickly and simultaneously; space-occupying lesions adjacent to these organs, and lesions outside the peritoneal cavity such as retroperitoneal hematomas, are also detected. While theoretical advantages are obviously attractive, the practical aspects of ultrasound may be the greatest limiting factors in its use. Until there is easy accessibility to both equipment and diagnostic expertise, ultrasound will only be of theoretical importance in most hospitals.
A diagnostic plan If the procedures I have described are available, the following plan of investigation in a patient with blunt abdominal trauma might be considered (Figs. 5A and 5B):
Computed axial tomography
* If there are positive abdominal signs, operate. * If abdominal signs are equivocal, do further tests: - Hematologic investigation is of some value. - Routine radiographic findings (e.g., air under diaphragm) may be indications for prompt exploration. * If doubt still exists, do peritoneal lavage: - Blood or leukocytes in effluent indicate need for laparotomy. - Faintly positive or negative lavage with equivocal clinical findings constitutes indication for further investigation. * Frequent physical examination for changing signs is essential. * Other procedures to aid diagnosis at this stage: - Repeat hematologic tests: may corroborate clinical findings. - Laparoscopy: in certain hands may indicate need for operation. - Scans, ultrasound for splenic, hepatic or other defects (e.g., detection of retroperitoneal hematoma or space-occupying lesion by ultrasound). * If abnormality is still questionable, perform angiography.
Computed axial tomography (or computer-assisted tomography) is a revolutionary, though costly, advance in the diagnosis of intra-abdominal lesions. Its future role in the investigation of blunt abdominal trauma may be determined at least in part by economic factors, but initial findings proving the efficacy of the technique are encouraging.
The precise investigative plan will vary according to opinions held in different centres as to the value of the various diagnostic techniques. Techniques such as angiography may well make it easier to decide whether to operate; for example, in the case of a hepatic injury a superficial laceration that stops bleeding does not require
laparotomy, whereas clear evidence of a large peripheral or central rupture necessitates intervention in most cases. Finally, ultrasonography may also aid in the diagnosis of other masses, especially retroperitoneal hematomas. These in most cases may be treated conservatively if the patient's clinical condition remains stable. References 1. TOVEE EB: Blunt abdominal trauma. / Trauma 10: 72, 1970 2. AHMAD W, POLK HC: Blunt abdominal trauma; a study of the relationship between diagnosis and outcome. South Med J 66: 1127, 1973 3. BRITTAIN RS: Liver trauma. Surg Clin North Am 43: 433, 1963 4. FREEARK RJ, CORLEY RD, NoRcRoss WJ: Unusual aspects of pancreatico-duodenal trauma. / Trauma 6: 484, 1966 5. Giuswou RA, COLLIER HS: Blunt abdominal trauma. mt Abstr Surg 112: 309, 1961 6. Lowa RJ, BOYD DR, FOLK FA, et al: The negative laparotomy for abdominal trauma. J Trauma 12: 853, 1972 7. PErrY AH: Abdominal injuries. Ann R Coil Surg Engi 53: 167, 1973 8. WILLIAMS RD, YURKO AA: Controversial aspects of diagnosis and management of blunt abdominal trauma. Am / Surg 111: 477, 1966 9. KLEINERT HE, RoMaso J: Blunt abdominal trauma. / Trauma 1: 226, 1961 10. NIcK WV, ZOLLINGER RW, WILLIAMS R.D: The diagnosis of. traumatic pancreatitis with blunt abdominal injuries. J Trauma 5: 495, 1965 11. PRATr DB, ANDERSEN RC, HITCHCOCK CR: Splenic rupture: a review of 114 cases. Mtnn Med 54: 177, 1971 12. SCHWARTZ SI, ADAMS iT, COCKETr AT, et al: Blunt trauma to the upper abdomen. Surg Annie 3: 273, 1971 13. BLAISDELL FW, TRUNKEY DD: Indications for laparotomy following blunt abdominal injury. West / Med 120: 502, 1974 14. LIEBERMAN RS, WELSH CS: A study of 248 instances of traumatic rupture of the spleen. Surg Gynecol Obstet 125: 725, 1967 15. PERRY iF .nt: A five-year survey of 152 acute abdominal injuries. J Trauma 5: 53, 1965 16. DIVINCENTI FC, RIvES JD, LABORDE EJ, et al: Blunt abdominal trauma. J Trauma 8: 1004, 1968 17. AHMAD W: Blunt abdominal trauma; a study of the relationship between diagnosis and outcome. Rev Surg 30: 215, 1973 18. FITZGERALD JB, CRAWFORD ES, DEBAKEY ME: Surgical considerations of non-penetrating abdominal injuries: an analysis of 200 cases. Am I Surg 100: 22, 1960 19. BERMAN JK, HABEGGER ED, FIELDS DC, et al: Blood studies as an aid in differential diagnosis of abdominal trauma. JAMA 165: 1537, 1957 20. JONES RC, SHIRES GT: The management of pancreatic injuries. Arch Surg 90: 502, 1965 21. FREEARK
RJ,
KANE
JM,
FOLK
FA,
et
al:
Traumatic disruptions of the head of the pancreas. Arch Surg 91: 5, 1965 22. OLSEN WR: Serum amylase in blunt abdominal trauma. / Trauma 13: 201, 1973
IZ...GAT.III
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FIG. 5A-Approach to patient with blunt abdominal trauma and equivocal abdom-
0. R. (or other S.Q.L.) FIG. SB-Possible modes of investigation when results of peritoneal lavage are negative
inal signs. or faintly positive. 604 CMA JOURNAL/MARCH 19, 1977/VOL. 116
23. WILLIAMs
24. 25. 26. 27. 28. 29. 30. 31. 32.
RD, ZOLLINGER RM:
Diagnostic
and prognostic factors in abdominal trauma. Am I Surg 97: 575, 1959 McCoRT JJ: Radiologic examination in blunt abdominal trauma. Radio! Clin North Am 2: 121, 1964 Idem: Rupture or laceration of the liver by non-penetrating trauma. Radiology 78: 49, 1962 YOUNG LW, ADAMS JT: Roentgen findings in localized trauma to the pancreas in children. Am I Roentgenol Radium Ther Nuci Med 101: 639, 1967 TING YM, REUTER SR: Hollow viscus injury in blunt abdominal trauma. Am J Roenigenol Radium Ther Nuci Med 119: 409, 1973 BOIJSEN E. JUDKINS MP, SIMAY A: Anglographic diagnosis of hepatic rupture. a lo ogy 86: 66, 1966 FREEARK RJ, Lova L, BAKER RJ: An active diagnostic approach to blunt abdominal trauma. Surg Clin North Am 48: 97, 1968 RooT HD, HAUSER CW, MCKINLEY CR, et al: Diagnostic perstoneal lavage. Surgery 57: 633, 1965 PERRY JF JR, DEMEULES JE, Roor HD: Diagnostic peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstet 131: 742, 1970 Roor HD, KItIZER, PJ, PERRY JF .ni: Pentoneal trauma: experimental and clinical studies. Surgery 62: 679, 1967
33. THAL ER, SHIRES GT: Peritoneal lavage in
blunt abdominal trauma. Am I Surg 125: 64, 1973
34. OLSEN WR,
REDMAN HC, HILORETh DH:
0O
Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104: 536, 1972 35. FREEDMAN GS: Radionuclide imaging of the injured patient. Radio! Clin North Am 11: 461, 1973 36. EVANS GW, CURTIN FG, MCCARTHY HF, et
al: Scintigraphy in lesions of liver and spleen. JAMA 222: 665, 1972 37. PoPovsIcY J, WIENER SN, FELDER PA, et al: Liver trauma: conservative management and the liver scan. Arch Surg 108: 184, 1974 38. NEBESAR RA, RAniINov KR, PoTSAID MS: Radionuclide imaging of the spleen in suspected splenic injury. Radiology 110: 609, 1974
S..
39. O'MARt. RE, HALL RC, DOMBROSKI DL: Scin-
A
tiscanning in the diagnosis of rupture of the spleen. Surg Gynecol Obstet 131: 1077, 1970
40. LUTZKER L, FREEMAN LM: The role of radio-
nuclide imaging in spleen trauma. Radiology 110: 419, 1974
41. MARTIN DJ, GRIScoM MT, NEWHAUSER EBD:
A further look at the total body opacification effect. Br I Radio! 45: 185, 1972 42. OssoRN DJ, GLICKMAN MG, GRNJA V: The role of angiography in abdominal nonArenal trauma. Radio! Clin North Am 11: 579, 1973 43. BURKE WS, MADIGAN JP: Roentgenologic diagnosis of rupture of liver and spleen as visualized by Thorotrast. Radiology 21: 580, 1933
AVEENO
AVEENO COLLOiDAL QILATED BATH OATMEAL 13ATh1
44. BERK RN, WHOLEY MH, STOCKDALE R: The
angiographic diagnosis of splenic and hepatic trauma. I Can Assoc Radio! 21; 230, 1970 45. BERK RN, WHOLEY MH: The application of splenic arteriography in the diagnosis of rupture of the spleen. Am I Roentgeno! Radium Ther Nuc! Med 104: 662, 1968 46. NEBESAR RA: Splenic rupture demonstrated by selective splenic artery angiogram. JAMA 187: 944, 1964 47. STEIN HL: The diagnosis of traumatic laceration of the spleen by selective arteriography, direct serial magnification angiography, and intra-arterial epinephrine. Radiology 93: 367, 1969
.ETWT.,
,,LA ..EE
48. MARGOLIAS MN, RING EJ, WALTMAN AC:
AVEENO 9 BAR
AVEENO * .
Arteriography in the management of hemorrhage from pelvic fractures. N Eng! I Med 287: 317, 1972
49. GASSANIGA AB, STANTON WV, BARTLEi-r RH:
Laparoscopy in the diagnosis of blunt and penetrating injuries to the abdomen. Am I Surg 131: 315, 1976 50. GOMEL V: Laparoscopy in general surgery. Ibid, p 319 51. SERSTE JP, THEUNIS A: Int6r& de la lapa-
**.
0@
**
.*....
.
6
roscopie dans les urgences abdominales traumatiques ou non. Acia Chir Belg 72: 387, 1973
52. RACHAIL
M,
CORALLO J, MAUREL G:
La
laparoscopie en urgence. Arch Fr Ma! App Dig 63: 103, 1974
53. TosnivIwr R, ROZENBERO H, CHAUVEINE L, et
al: Plaidoyer pour 1a laparoscopie dans les traumatismes abdomin.ux ferm.s. I Chir (Paris) 192: 77, 1971
54. AYALA
LA,
WILLIAMS
LF, WIDIucH WC:
Occult rupture of the spleen. Ann Surg 179: 473, 1974
*
55. HOM HH, KRISTENSEN JK, RASMUSSEN SN,
et al: Indications for ultrasonic scanning in abdominal diagnostics. I Clin Ultrasound 2: 5, 1974
CMA JOURNAL/MARCH 19, 1977/VOL. 116 605
From the Toronto Western Hospital Reprint requests to: Dr. B. Taylor, Toronto Western Medical Building, Ste. 103, 25 Leonard Ave., Toronto, Ont. M5T 2R2
lowing: hematologic investigation, routine radiography, peritoneal lavage, scanning procedures, angiography, laparoscopy, endoscopy, ultrasonography and computer-assisted tomography. Long-standing techniques such as blood work and radiography have often been inadequate, but they will be reviewed briefly with emphasis on the few instances in which they can be valuable. Hematologic investigation
The report by Berman and associates19 in 1957 that in patients with liver and spleen injuries leukocyte counts (x 1O./ 1) averaged 24.0 and 19.0, respectively, led to enthusiasm for the specificity of this test. Although some authors corroborated this finding9 (even estimating degree of hlood loss on the basis of the leukocyte count13), most studies have found that leukocytosis is extremely variable and can follow trauma to the abdominal wall and kidneys or even to the head or limbs in the absence of serious abdominal injury.2'3'8 Although an elevated leukocyte count may suggest an abdominal injury, any conclusion about the type or presence of an intra-abdominal lesion is dangerous. The value of serum amylase determinations also is controversial. Since the clinical presentation of pancreaticoduodenal lesions often is insidious, a simple diagnostic test would be helpful. Many favour repeated serum amylase determinations to monitor the development of a pancreatic lesion;20 Freeark and associates21 even suggested that hyperamylasemia associated with upper abdominal pain is an indication for Iaparotomy. This aggressive approach results from the reported high incidence of pseudocyst formation in unexplored traumatic pancreatitis10'21 and the increased frequency of multiple organ involvement when the panqreas is injured. Determination of urinary .imylase concentration is more sensitive than that of serum amylase, and the former has therefore been advocated.4 Olsen,22 however, showed that one third of patients with hyperamylasemia had no serious injury at laparotomy, and in none was the serum amylase value the only indication of pancreatic trauma; he therefore concluded that the value of this biochemical test had been overestimated. Perhaps a middle ground between these divergent opinions is sensible; hyperamylasemia after blunt abdominal trauma may be only a suggestion of pancreatic injury, but an increasing or persistent value that supports corroborating clinical signs is undoubtedly of value. Although the hematocrit determined early is of no specific value in the assessment of blood loss into the abdo-
men, repeated determinations may detect continuing hemorrhage. These investigations, valuable as they may be in a relative way, are not helpful in making precise diagnoses in blunt trauma. Routine radiography
Plain radiographs reportedly aid assessment of the injured abdomen in only 33% of cases.2'18'23 Accuracy depends on many factors, including obesity, general condition of the patient and the technique used. Detailed reports have described the numerous radiographic findings of fluid in the abdomenM.. and of specific problems such as splenic injury and traumatic pancreatitis.28 These changes are usually subtle and inconstant. Despite their acknowledged shortcomings routine radiographs are diagnostic in a few cases of intra-abdominal injury, as follows: 1. Perforated viscus. Free air in the peritoneal cavity, whether under the diaphragm in the upright position or under the costal margin in the left lateral decubitus position, indicates a perforated viscus and is an undisputed indication for operation. Consequently it is a potentially valuable sign. even though it is present in only about 10% of cases of rupture of the small bowel27 and in a somewhat higher percentage of gastric and colonic perforations. 2. Retroperitoneal rupture. The loss of distinct psoas margins or bubbles outside the usual bowel markings strongly suggests entrapment of air from a perforated hollow viscus.27 If such is seen in the right upper quadrant, retroperitoneal duodenal rupture has to be considered. 3. Diaphragmatic rupture. Traumatic diaphragmatic hernia is often diagnosed incidentally from typical findings on plain abdominal and chest films.1 A hollow viscus in the thorax, shift of the heart and mediastinum to the right and atelectasis in the left lower lobe may all be demonstrated. Contrast studies (barium or watersoluble medium) of the gastrointestinal tract aid the assessment of blunt trauma. They may confirm the presence of an intramural hematoma of the duodenum27 or traumatic diaphragmatic hernia, localize an occult perforation of the stomach, duodenum or colon, or outline a swollen, boggy pancreas by demonstrating deviation of the stomach and duodenal loop.26 Intravenous cholangiograms occasionally help to confirm injury to the biliary tree. The importance of radiography of the genitourinary tract is discussed by Ranking elsewhere in this issue (page 617). In general, if there is any doubt of renal injury, and especially if hema-
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tuna is evident, excretory urography should be performed in the emergency department. Paracentesis and peritoneal lavage
The four-quadrant abdominal tap was once extensively used, and the exponents of this rather crude procedure reported an accuracy of 75 to 80% *16,23 However, the false-negative rate is 10 to 50% . explaining the adage of Freeark, Love and Baker29 that "negative means nothing". In 1965 Root and colleagues30 described diagnostic peritoneal lavage, certainly the most important recent advance in investigation of abdominal trauma. They were able to demonstrate 100% accuracy in determining the presence or absence of abdominal injury in 28 patients. Little has been added to the original techniques, which are recognized and used widely. The technique is the following: After preparation of the abdomen and emptying of the bladder, an area 5.0 to 7.5 cm below the umbilicus is infiltrated with 2% lidocaine and a subumbilical incision is made in the midline. With the recti tensed (which is often not possible because of the general condition of the patient) a percutaneous peritoneal cannula is introduced into the peritoneal cavity in the direction of the pelvis. The immediate return of nonclotted fresh blood signifies appreciable intraperitoneal hemorrhage and is an indication for laparotomy. Otherwise, 1 1 of normal saline is instilled into the abdomen and left for 1 minute, after which it is evacuated by siphoning. The entire investigation takes just a few minutes, and information is immediately available. Interpretation of the nature of the effluent is critical; the finding of frank blood-staining in the returning fluid is of great importance since 88% of deaths from blunt abdominal trauma are due to hemorrhage.23 The fluid will appear salmon pink when 1 to 5 ml of blood is added to 1000 ml of saline;6'13 a further 5 to 10 ml turns the solution an intense red. Perry, DeMeules and Root31 have stated that a quantitative erythrocyte measurement of 0.1 x 1012/ml, representing a hemorrhage of 22 ml into the peritoneal cavity, is an indication for laparotomy. Interpretation of the presence of leukocytes is somewhat more qualitative; Root, Keizer and Perry32 proved that an effluent containing neutrophils demonstrates visceral injury, and added that leukocytes can be detected in the peritoneal fluid only when 2 hours have elapsed from the time of injury. Intraperitoneal intestinal content, amylase, bacteria and bile can be recognized as well, though presence of the last three are not clear operative indications but must be assessed along with other investigations.
The diagnostic peritoneal lavage is highly reliable, with a rate of falsenegative results of 0 to 2% and of false-positives, up to 4%. Peritoneal lavage, however, does have disadvantages. First, no conclusions can be drawn about the site of abdominal injury. Second, complications do occur: Thai and Shires33 reported complications in 4.5% of patients, including abdominal wall infusions, bleeding, lack of fluid return, penetration of an epiploic vein and penetration of the bladder. (To decrease the frequency of these complications Perry, DeMeules and Root31 altered their original method slightly, inserting the cannula under direct vision into the peritoneal cavity.) Third, diagnostic peritoneal lavage may be too sensitive. Certainly, a negative result indicates that there is no serious injury in the peritoneal cavity - as already stated, there are very few false-negative results. In fact, in the original series of Root and colleagues30 two patients in whom results had been negative required operation because of changing clinical signs, and no intraperitoneal injury was found. A positive result of lavage, however, often presents a dilemma. In up to 30% of patients in whom lavage was positive, with salmon-pink effluent, laparotomy revealed lesions that did not really require surgical management.. Bleeding from the abdominal wall, minor hepatic lacerations, mesenteric tears or retroperitoneal hematomas are easily detected by this diagnostic method, but the patient may be better off if these lesions are not recognized, as they usually resolve without surgical intervention. The solution to this problem is not easy and requires consideration of other diagnostic aids and an overall plan for investigation in the patient with equivocal findings. At present some surgeons3. advocate the use of this procedure in every case of suspected in.ra-abdominal trauma, while others,2 including myself, reserve it for the difficult cases. If doubt still exists after lavage, radionuclide imaging may be of value.
about 10 or 15 minutes. Splenic rupture is characterized by linear, wedge-shaped, stellate or concave defects extending inwards from the splenic margin. Evans and colleagues36 claimed that lesions as small as 1 cm can be detected, but most authors35'37 have suggested that, to be recognized, the defect must be 2 to 3 cm. Nebesar, Rabinov and Potsaid36 reported high accuracy with two falsepositive results and one false-negative scan in 32 patients with splenic injury proven at operation. These authors contended that the accuracy of the examination compares favourably with that of angiography. In another report Evans and associates36 diagnosed five cases of traumatic intrasplenic hema-
FIG. i-Value of scan of spleen in 15year-old girl who had fallen from horse 3 weeks previously and became anemic. Anterior view demonstrates defect proved at laparotomy to be large subcapsular hematoma (arrows).
toma, all confirmed at laparotomy, and had no false-positive results. Although scanning has not been used universally in blunt abdominal trauma the advantages are encouraging. The procedure is noninvasive and may be performed with virtually no risk - the patient is exposed to little radiation and the test can therefore be repeated if necessary. The results are more specific than those of diagnostic peritoneal lavage, localizing the site of injury in many instances. Also, positive scans have been reported in the presence of negative lavage;36'39 theoretically a subcapsular hematoma of the liver or spleen can be detected before rupture and therefore prior to the development of peritoneal signs or a positive lavage. The usefulness of the spleen scan in two patients with equivocal clinical presentations is demonstrated in Figs. 1 and 2. Liver trauma can also be detected by scintigraphy. As in the case of the spleen, a variety of defects such as lacerations, subcapsular hematomas and central stellate fractures have been described. As with peritoneal lavage there are certain disadvantages of scanning. The proportion of false-positive and falsenegative results remains higher than with angiography, and O'Mara, Hall and Dombroski39 and Lutzker and Freeman40 have suggested that additional views such as obliques and angulated scans can minimize the occurrence of false-positive results (Fig. 3). Although scans are noninvasive, they require time, which may not be available in treating a sick patient with multiple injuries, especially if additional views to clarify problems inherent in the technique are needed. Even though scanning usually takes little time, few
Scanning procedures
Scanning has been used mainly in cases of splenic, hepatic and renal injuries, though scattered reports of bladder, aortic and pancreatic imaging have appeared.35 The indications for these studies are the same as those for layage; for example, when the clinical assessment of a patient is compromised by any of the factors noted above and more information is needed. In hepatic and splenic scanning, technetium-99m sulfur colloid is injected intravenously and images in three planes are then developed. The entire procedure takes
FIG. 2-Value of splemc scan in 30-yearold man who had sustained punch to right side of abdomen 4 days earlier and became anemic. Splenic scan suggested fractures of spleen (arrows); ruptured spleen was later removed.
FIG. 3-False-positive splenic scan in 55year-old woman who sustained injuries to left kidney and left lower ribs. Scan apparently demonstrated fracture-like defect (arrows), but celiotomy failed to reveal injury.
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emergency departments contain scanning equipment and the patient must be moved to the nuclear medicine laboratory. While scintigraphy localizes small defects in abdominal organs, it is not specific for the type of lesion present. Evans and . pointed out that many pre-existing lesions, particularly in the spleen (for example, celiac disease and splenic infarct) produce abnormalities similar to those after trauma. Finally, the scan, like diagnostic layage, does not give an indication of when to operate. Popovsky and associates37 reported scintigraphic diagnosis of several major hepatic injuries such as large fractures, subcapsular hematomas and central hepatic defects; five patients with such lesions were treated conservatively and all five did well. Similarly, splenic defects do not necessarily require surgical treatment. Although most surgeons would remove the spleen if a reasonable chance of a subcapsular hematoma existed, uneventful recovery has occurred with conservative management after splenic defects were demonstrated.39 Organs other than the liver and spleen have been imaged, but the practical use of these scans has not been defined. Whole-body opacification led to the diagnosis of a paraduodenal hematoma in a child,41 but the scope of this procedure is questionable. How, then, does one make the diagnosis in the patient who has equivocal signs, a negative lavage and a scan that shows a small defect in the liver or spleen? Angiography may be the answer. Angiography Indications for abdominal angiography after blunt trauma, though few, are definitely increasing as the enthusiam for this procedure grows.28'29"."42 As early as 1933.. an angiographic image produced by Thorotrast outlined hepatic injury, but dangerous side effects precluded the long-term use of this substance. Angiography may be indicated in the case of the patient whose condition is stable but in whom the findings are equivocal, and the results of other investigations are inconclusive; it may also be considered when there is unexplained blood loss, or a vascular lesion is suspected,28 or, as noted by Ranking elsewhere in this issue, in cases of renal trauma. It is a relatively safe procedure,4446 with few complications other than small groin hematomas and thromboses. Whether aortography or selective angiography is performed seems to depend on the particular radiologist's preference. Those favouring an aortic-
flush technique contend that this procedure requires less time and skill than the selective study and provides equally useful information. Angiography has several advantages: 1. Specific diagnoses can be made and information provided as to the exact nature and size of the traumatic lesion in the spleen, liver or kidneys. The detail is excellent and can be improved by intra-arterial injection of epinephrine, which constricts normal vessels, accentuating the abnormal findings.47 In the case of a ruptured spleen, subtle diagnostic signs such as extravasation, mottled parenchymal phase, arteriovenous shunts, early venous opacification, variation in vessel course, and discontinuity of splenic contour may be recognized.42 Distinct types of abnormality are also found in the injured liver.28 2. The accuracy is extremely high. There are virtually no false-negative results and very few false-positive results.42'"'45 3. Renal as well as splenic and hepatic vessels are visualized at the same time, thus providing valuable information about several organs frequently involved in a patient with multiple trauma.44'45 4. Hepatic vascular anatomy is demonstrated, aiding in hepatic lobectomy if this becomes necessary. 5. Therapeutic angiography appears to be beneficial: Margolias, Ring and Waltman48 described control of pelvic hematomas by injection of autologous clot into appropriate pelvic arteries. Despite its usefulness (Fig. 4) emergency angiography after blunt abdominal trauma is an invasive procedure that takes at least 30 to 45 minutes and often longer. Few complications, however, have been reported.
Laparoscopy Though not widely used in North America,49'50 laparoscopy has frequently been found useful in Europe. Serste and Theunis51 described 27 laparoscopies for trauma, and, though they diagnosed the type of injury in most cases, they were unable to determine the site of bleeding in many of the 12 cases of hemoperitoneum. However, Rachail, Corallo and Maurel52 accurately diagnosed 11 of 14 injuries to liver, spleen, diaphragm, pancreas and abdominal wall. Tostivint and colleagues53 had similar success in detecting intraperitoneal trauma. Many surgeons on this continent would probably question whether a procedure that requires both an incision and the instillation of several litres of carbon dioxide into the abdomen has an advantage over one requiring a slightly larger incision that permits direct examination. Even so, laparoscopy may have a place, especially if general surgeons in addition to gynecologists become adept with the specialized instrumentation, and if the improved expertise allows the procedure to be done under local anesthesia using less gas. In fact, there are reports of laparoscopy being carried out under just these latter, less traumatic, conditions. Endoscopy Although it is conceivable that upper or lower intestinal endoscopy (including retrograde pancreatography) might contribute to the abdominal assessment, no supportive evidence has developed. Ufirasonography A new investigative technique is abdominal echography. The B scanner emits high frequency sound waves that are reflected off tissues of different densities. The returning sound waves are detected by a crystal, and an image
FIG. 4-Usefulness of angiography in 43-year-old woman whose iliac crest was fractured. She was sent home after examination in emergency department. She returned next day with left upper quadrant pain and persistent hiccoughs. Although condition clinically was stable, posterior view of splenic scan (left) showed small defect (arrows). Repeat scan was equivocal but arteriogram (right) suggested normal vascular architecture (arrows). Conservative treatment and uneventful recovery followed.
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of all interfaces in that section of the body is reconstructed. The detailed outline of intra-abdominal structures permits one to identify the liver, stomach, pancreas, bowel, kidneys, spleen and retroperitoneal area. Although few reports have appeared in recent journals one may state that critical information about intra-abdominal injuries can easily be obtained by ultrasound.54 Hom and colleagues55 gave an example of a retroperitoneal hematoma located behind the left kidney in one patient and a large hematoma situated adjacent to the spleen in another. Neither injury might have been detected by all other investigations. The possible contributions of ultrasonography are several. Unlike the other methods described it is truly noninvasive. The accuracy of the technique continues to increase as better scanners are developed. More important, all organs and masses are scanned quickly and simultaneously; space-occupying lesions adjacent to these organs, and lesions outside the peritoneal cavity such as retroperitoneal hematomas, are also detected. While theoretical advantages are obviously attractive, the practical aspects of ultrasound may be the greatest limiting factors in its use. Until there is easy accessibility to both equipment and diagnostic expertise, ultrasound will only be of theoretical importance in most hospitals.
A diagnostic plan If the procedures I have described are available, the following plan of investigation in a patient with blunt abdominal trauma might be considered (Figs. 5A and 5B):
Computed axial tomography
* If there are positive abdominal signs, operate. * If abdominal signs are equivocal, do further tests: - Hematologic investigation is of some value. - Routine radiographic findings (e.g., air under diaphragm) may be indications for prompt exploration. * If doubt still exists, do peritoneal lavage: - Blood or leukocytes in effluent indicate need for laparotomy. - Faintly positive or negative lavage with equivocal clinical findings constitutes indication for further investigation. * Frequent physical examination for changing signs is essential. * Other procedures to aid diagnosis at this stage: - Repeat hematologic tests: may corroborate clinical findings. - Laparoscopy: in certain hands may indicate need for operation. - Scans, ultrasound for splenic, hepatic or other defects (e.g., detection of retroperitoneal hematoma or space-occupying lesion by ultrasound). * If abnormality is still questionable, perform angiography.
Computed axial tomography (or computer-assisted tomography) is a revolutionary, though costly, advance in the diagnosis of intra-abdominal lesions. Its future role in the investigation of blunt abdominal trauma may be determined at least in part by economic factors, but initial findings proving the efficacy of the technique are encouraging.
The precise investigative plan will vary according to opinions held in different centres as to the value of the various diagnostic techniques. Techniques such as angiography may well make it easier to decide whether to operate; for example, in the case of a hepatic injury a superficial laceration that stops bleeding does not require
laparotomy, whereas clear evidence of a large peripheral or central rupture necessitates intervention in most cases. Finally, ultrasonography may also aid in the diagnosis of other masses, especially retroperitoneal hematomas. These in most cases may be treated conservatively if the patient's clinical condition remains stable. References 1. TOVEE EB: Blunt abdominal trauma. / Trauma 10: 72, 1970 2. AHMAD W, POLK HC: Blunt abdominal trauma; a study of the relationship between diagnosis and outcome. South Med J 66: 1127, 1973 3. BRITTAIN RS: Liver trauma. Surg Clin North Am 43: 433, 1963 4. FREEARK RJ, CORLEY RD, NoRcRoss WJ: Unusual aspects of pancreatico-duodenal trauma. / Trauma 6: 484, 1966 5. Giuswou RA, COLLIER HS: Blunt abdominal trauma. mt Abstr Surg 112: 309, 1961 6. Lowa RJ, BOYD DR, FOLK FA, et al: The negative laparotomy for abdominal trauma. J Trauma 12: 853, 1972 7. PErrY AH: Abdominal injuries. Ann R Coil Surg Engi 53: 167, 1973 8. WILLIAMS RD, YURKO AA: Controversial aspects of diagnosis and management of blunt abdominal trauma. Am / Surg 111: 477, 1966 9. KLEINERT HE, RoMaso J: Blunt abdominal trauma. / Trauma 1: 226, 1961 10. NIcK WV, ZOLLINGER RW, WILLIAMS R.D: The diagnosis of. traumatic pancreatitis with blunt abdominal injuries. J Trauma 5: 495, 1965 11. PRATr DB, ANDERSEN RC, HITCHCOCK CR: Splenic rupture: a review of 114 cases. Mtnn Med 54: 177, 1971 12. SCHWARTZ SI, ADAMS iT, COCKETr AT, et al: Blunt trauma to the upper abdomen. Surg Annie 3: 273, 1971 13. BLAISDELL FW, TRUNKEY DD: Indications for laparotomy following blunt abdominal injury. West / Med 120: 502, 1974 14. LIEBERMAN RS, WELSH CS: A study of 248 instances of traumatic rupture of the spleen. Surg Gynecol Obstet 125: 725, 1967 15. PERRY iF .nt: A five-year survey of 152 acute abdominal injuries. J Trauma 5: 53, 1965 16. DIVINCENTI FC, RIvES JD, LABORDE EJ, et al: Blunt abdominal trauma. J Trauma 8: 1004, 1968 17. AHMAD W: Blunt abdominal trauma; a study of the relationship between diagnosis and outcome. Rev Surg 30: 215, 1973 18. FITZGERALD JB, CRAWFORD ES, DEBAKEY ME: Surgical considerations of non-penetrating abdominal injuries: an analysis of 200 cases. Am I Surg 100: 22, 1960 19. BERMAN JK, HABEGGER ED, FIELDS DC, et al: Blood studies as an aid in differential diagnosis of abdominal trauma. JAMA 165: 1537, 1957 20. JONES RC, SHIRES GT: The management of pancreatic injuries. Arch Surg 90: 502, 1965 21. FREEARK
RJ,
KANE
JM,
FOLK
FA,
et
al:
Traumatic disruptions of the head of the pancreas. Arch Surg 91: 5, 1965 22. OLSEN WR: Serum amylase in blunt abdominal trauma. / Trauma 13: 201, 1973
IZ...GAT.III
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FIG. 5A-Approach to patient with blunt abdominal trauma and equivocal abdom-
0. R. (or other S.Q.L.) FIG. SB-Possible modes of investigation when results of peritoneal lavage are negative
inal signs. or faintly positive. 604 CMA JOURNAL/MARCH 19, 1977/VOL. 116
23. WILLIAMs
24. 25. 26. 27. 28. 29. 30. 31. 32.
RD, ZOLLINGER RM:
Diagnostic
and prognostic factors in abdominal trauma. Am I Surg 97: 575, 1959 McCoRT JJ: Radiologic examination in blunt abdominal trauma. Radio! Clin North Am 2: 121, 1964 Idem: Rupture or laceration of the liver by non-penetrating trauma. Radiology 78: 49, 1962 YOUNG LW, ADAMS JT: Roentgen findings in localized trauma to the pancreas in children. Am I Roentgenol Radium Ther Nuci Med 101: 639, 1967 TING YM, REUTER SR: Hollow viscus injury in blunt abdominal trauma. Am J Roenigenol Radium Ther Nuci Med 119: 409, 1973 BOIJSEN E. JUDKINS MP, SIMAY A: Anglographic diagnosis of hepatic rupture. a lo ogy 86: 66, 1966 FREEARK RJ, Lova L, BAKER RJ: An active diagnostic approach to blunt abdominal trauma. Surg Clin North Am 48: 97, 1968 RooT HD, HAUSER CW, MCKINLEY CR, et al: Diagnostic perstoneal lavage. Surgery 57: 633, 1965 PERRY JF JR, DEMEULES JE, Roor HD: Diagnostic peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstet 131: 742, 1970 Roor HD, KItIZER, PJ, PERRY JF .ni: Pentoneal trauma: experimental and clinical studies. Surgery 62: 679, 1967
33. THAL ER, SHIRES GT: Peritoneal lavage in
blunt abdominal trauma. Am I Surg 125: 64, 1973
34. OLSEN WR,
REDMAN HC, HILORETh DH:
0O
Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104: 536, 1972 35. FREEDMAN GS: Radionuclide imaging of the injured patient. Radio! Clin North Am 11: 461, 1973 36. EVANS GW, CURTIN FG, MCCARTHY HF, et
al: Scintigraphy in lesions of liver and spleen. JAMA 222: 665, 1972 37. PoPovsIcY J, WIENER SN, FELDER PA, et al: Liver trauma: conservative management and the liver scan. Arch Surg 108: 184, 1974 38. NEBESAR RA, RAniINov KR, PoTSAID MS: Radionuclide imaging of the spleen in suspected splenic injury. Radiology 110: 609, 1974
S..
39. O'MARt. RE, HALL RC, DOMBROSKI DL: Scin-
A
tiscanning in the diagnosis of rupture of the spleen. Surg Gynecol Obstet 131: 1077, 1970
40. LUTZKER L, FREEMAN LM: The role of radio-
nuclide imaging in spleen trauma. Radiology 110: 419, 1974
41. MARTIN DJ, GRIScoM MT, NEWHAUSER EBD:
A further look at the total body opacification effect. Br I Radio! 45: 185, 1972 42. OssoRN DJ, GLICKMAN MG, GRNJA V: The role of angiography in abdominal nonArenal trauma. Radio! Clin North Am 11: 579, 1973 43. BURKE WS, MADIGAN JP: Roentgenologic diagnosis of rupture of liver and spleen as visualized by Thorotrast. Radiology 21: 580, 1933
AVEENO
AVEENO COLLOiDAL QILATED BATH OATMEAL 13ATh1
44. BERK RN, WHOLEY MH, STOCKDALE R: The
angiographic diagnosis of splenic and hepatic trauma. I Can Assoc Radio! 21; 230, 1970 45. BERK RN, WHOLEY MH: The application of splenic arteriography in the diagnosis of rupture of the spleen. Am I Roentgeno! Radium Ther Nuc! Med 104: 662, 1968 46. NEBESAR RA: Splenic rupture demonstrated by selective splenic artery angiogram. JAMA 187: 944, 1964 47. STEIN HL: The diagnosis of traumatic laceration of the spleen by selective arteriography, direct serial magnification angiography, and intra-arterial epinephrine. Radiology 93: 367, 1969
.ETWT.,
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48. MARGOLIAS MN, RING EJ, WALTMAN AC:
AVEENO 9 BAR
AVEENO * .
Arteriography in the management of hemorrhage from pelvic fractures. N Eng! I Med 287: 317, 1972
49. GASSANIGA AB, STANTON WV, BARTLEi-r RH:
Laparoscopy in the diagnosis of blunt and penetrating injuries to the abdomen. Am I Surg 131: 315, 1976 50. GOMEL V: Laparoscopy in general surgery. Ibid, p 319 51. SERSTE JP, THEUNIS A: Int6r& de la lapa-
**.
0@
**
.*....
.
6
roscopie dans les urgences abdominales traumatiques ou non. Acia Chir Belg 72: 387, 1973
52. RACHAIL
M,
CORALLO J, MAUREL G:
La
laparoscopie en urgence. Arch Fr Ma! App Dig 63: 103, 1974
53. TosnivIwr R, ROZENBERO H, CHAUVEINE L, et
al: Plaidoyer pour 1a laparoscopie dans les traumatismes abdomin.ux ferm.s. I Chir (Paris) 192: 77, 1971
54. AYALA
LA,
WILLIAMS
LF, WIDIucH WC:
Occult rupture of the spleen. Ann Surg 179: 473, 1974
*
55. HOM HH, KRISTENSEN JK, RASMUSSEN SN,
et al: Indications for ultrasonic scanning in abdominal diagnostics. I Clin Ultrasound 2: 5, 1974
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