Isolated Free Fluid on Computed Tomographic Scan in Blunt Abdominal Trauma: A Systematic Review of Incidence and Management

Background Gallbladder perforation is a very rare finding in children. Clinical and radiografic presentations are often vague. Hence it is a challenging diagnosis, often missed during initial evaluation with potentially fatal consequences. The aim of this case report and review was to identify factors that might help to diagnose and manage future cases. Methods We present a case of gallbladder perforation in an 8-year-old child after blunt abdominal trauma caused by a handlebar in which imaging modalities such as ultrasound and magnetic resonance imaging (MRI) helped us to determine proper management. We identified and evaluated comparable cases for isolated traumatic gallbladder injury. A review of the recent literature was performed by online search in Pubmed and Google Scholar using “gallbladder injury in children”, “gallbladder perforation children”, “blunt abdominal trauma children” as keywords. We focused on articles exclusively in the pediatric section. The literature from the period 2000–2020 was taken into account to review the state of the art in diagnosis and management. Results and Conclusion Recent literature for gallbladder injury in pediatrics is sparse compared to the adult counterpart. Only eight published cases of isolated gallbladder injury in children were identified. Since the onset of symptoms may not develop acutely and often develops in an indistinct manner, radiografic examinations play an important role in the diagnostic progress. The authors advise caution in cases of blunt abdominal trauma especially involving handlebars, intraperitoneal free fluid, and severe abdominal pain. We advocate high suspicion of gallbladder perforation if the gallbladder wall displays discontinuation or cannot be definitively differentiated in sonografic examination. Echogenic fluid within the gallbladder should always lead to suspicion of intraluminal bleeding. Repeated clinical and imaging examinations are mandatory since the onset of signs and symptoms may be delayed. Key Points: Citation Format

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Isolated free fluid on computed tomography for blunt abdominal trauma

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0078 ◽

2019 ◽

Vol 101 (8) ◽

pp. 552-557

Author(s):

W Bekker ◽

MTD Smith ◽

VY Kong ◽

JL Bruce ◽

G Laing ◽

...

Keyword(s):

Abdominal Trauma ◽

Blunt Abdominal Trauma ◽

Splenic Injury ◽

Operative Management ◽

Bladder Injury ◽

Free Fluid ◽

Abdominal Ct ◽

Hollow Viscus ◽

Hollow Viscus Injury ◽

Non Operative Management

Introduction The clinical significance of isolated free fluid on abdominal computed tomography (CT) in patients with blunt abdominal trauma is unclear. This audit reviews our unit’s experience with isolated free fluid and attempts to refine our clinical algorithms for the assessment of patients with blunt abdominal trauma. Materials and methods All patients who sustained blunt abdominal trauma between December 2012 and December 2017 who were subjected to multidetector CT of the abdomen as part of their initial investigation were included in this study. Results During the five-year period under review, a total of 1066 patients underwent abdominal CT following blunt poly trauma. A total of 84 (7.9%) patients died. There were 148 (14%) patients with CT finding of isolated free fluid. Of these, 128 (67%) were selected for non-operative management, which included a period of serial abdominal examinations. In this non-operative group, five patients failed their abdominal observations and underwent laparotomy. Findings in these five cases were negative (1), non-therapeutic (1), splenic injury (1), Pancreatic and splenic injury (1) and bladder injury (1). Thirteen patients (10%) died, none of whom had surgery. The causes of death were exsanguination from a major traumatic lower limb injury (1), multiple organ failure (1), traumatic brain injury (10) and spinal cord injury (1). The remaining 20 patients underwent laparotomy. The indications were failed non-operative management (5), abdominal distension (1) and suspicion of a missed hollow viscus injury (14). In this group there were 11 therapeutic and 6 non-therapeutic surgeries and three negative laparotomies. For the 15 patients selected for operative management, the findings were as follows: hollow viscus injury (3), mesenteric bleeds (2), splenic and pancreatic injury (1), liver and bladder injury (1), splenic and bladder injury (1), non-therapeutic (4), negative (3). The finding of isolated free fluid on CT is 98% sensitive and 96% specific for true isolated free fluid (chi square 331.598; P = 0.000). This finding predicts successful non-operative management with a positive predictive value of 93% and a negative predictive value of 96%. Discussion In patients with blunt abdominal trauma, the finding of isolated free fluid on abdominal CT alone is no longer an indication for laparotomy. Other clinical factors must be taken into account when deciding on the need for laparotomy, such as haemodynamic status, clinical abdominal findings and the ability to reliably assess the abdomen. In the absence of a clinical indication for urgent laparotomy, patients with isolated free fluid may be observed.

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Intra-abdominal Free Fluid without Solid Organ Injury in Blunt Abdominal Trauma: An Indication for Laparotomy

Journal of Trauma and Acute Care Surgery ◽

10.1097/00005373-200206000-00019 ◽

2002 ◽

Vol 52 (6) ◽

pp. 1134-1140 ◽

Cited By ~ 73

Author(s):

Alexander K. T. Ng ◽

Richard K. Simons ◽

William C. Torreggiani ◽

Stephen G. F. Ho ◽

Andrew W. Kirkpatrick ◽

...

Keyword(s):

Abdominal Trauma ◽

Blunt Abdominal Trauma ◽

Organ Injury ◽

Free Fluid ◽

Solid Organ ◽

Solid Organ Injury

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The spectrum and outcome of blunt trauma related enteric hollow visceral injury

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2018.0013 ◽

2018 ◽

Vol 100 (4) ◽

pp. 290-294 ◽

Cited By ~ 4

Author(s):

W Bekker ◽

VY Kong ◽

GL Laing ◽

JL Bruce ◽

V Manchev ◽

...

Keyword(s):

Blunt Trauma ◽

Abdominal Trauma ◽

Blunt Abdominal Trauma ◽

Delayed Diagnosis ◽

Free Fluid ◽

Visceral Injury ◽

X Ray ◽

Median Delay ◽

Chest X Ray ◽

Hollow Visceral Injury

Introduction This audit focused on patients who sustained enteric injury following blunt abdominal trauma. Methods Our prospectively maintained electronic registry was interrogated retrospectively, and all patients who had sustained blunt abdominal trauma between December 2011 and January 2016 were identified. Results Overall, 2,045 patients had sustained blunt abdominal trauma during the period under review. Seventy per cent were male. The median age was 28 years. Sixty patients (2.9%) sustained a small bowel injury (SBI). Thirty-five of these were peritonitic on presentation. All patients with a SBI had a chest x-ray and free air was present in seven. In 18 patients with a SBI, computed tomography (CT) was performed, which revealed isolated free fluid in 12 and free intraperitoneal air in 5. In five cases, the CT was normal. A total of 32 patients (1.5%) sustained blunt duodenal trauma (BDT). All patients with BDT had a chest x-ray on presentation. Free intraperitoneal air was not present in any. CT was performed on 17 patients with BDT. This revealed isolated free fluid or retroperitoneal air in 12. The median delay between injury and presentation for these enteric injures was 15.5 hours (interquartile range [IQR]: 8–25 hours) while between presentation at hospital and operation, the median delay was 6 hours (IQR: 3–13 hours). Conclusions Blunt trauma related enteric hollow visceral injury remains associated with delayed diagnosis and significant morbidity. It can be caused by a disparate array of mechanisms and is difficult to diagnose even with modern imaging strategies.

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Free Fluid Accumulation following Blunt Abdominal Trauma: Potential for Expansion of the Fast Protocol

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790901600202 ◽

2009 ◽

Vol 16 (2) ◽

pp. 70-75

Author(s):

N Simpson ◽

P Page ◽

DM Taylor

Keyword(s):

Abdominal Trauma ◽

Blunt Abdominal Trauma ◽

Peritoneal Fluid ◽

Injury Severity ◽

Iliac Fossa ◽

Fluid Collection ◽

Rectus Muscle ◽

Ct Scans ◽

Free Fluid ◽

The Right

Objective To determine sites of free intra-peritoneal fluid collection following blunt abdominal trauma, with a view to refinement of the Focused Assessment by Sonography for Trauma (FAST) protocol. Methods This was a retrospective observational study of CT scans of subjects who had suffered blunt abdominal trauma and had free intra-peritoneal fluid detected on CT scan within 24 hours. The depth from the skin and amount of fluid at 14 abdominal sites were determined. Results CT scans of 105 patients were examined: 68 (64.8%) were male, mean age 36.7±18.4 years, mean injury severity score 25.4±11.6. Fluid collected most commonly at three sites: right mid-axillary line at the level of the xiphisternum (52 patients, 49.5%), lateral margin of the right rectus muscle at the level of the anterior superior iliac spine (49 patients, 46.7%) and right mid-axillary line at the level of the umbilicus (40 patients, 38.1%). Mean depth of fluid at these sites were 3.6, 3.6 and 4.2 cm, respectively. Conclusions Free fluid collects commonly in the area of the right iliac fossa following blunt abdominal trauma. The inclusion of this site in the FAST protocol may increase the ultrasonographic detection of free fluid in the acute trauma setting.

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Management of solid organ injury in patient of blunt abdominal trauma

International Surgery Journal ◽

10.18203/2349-2902.isj20213129 ◽

2021 ◽

Vol 8 (8) ◽

pp. 2361

Author(s):

Aafrin S. Baldiwala ◽

Vipul C. Lad

Keyword(s):

Cause Of Death ◽

Abdominal Trauma ◽

Blunt Abdominal Trauma ◽

Road Traffic ◽

Correct Diagnosis ◽

Organ Injury ◽

Common Mechanism ◽

Free Fluid ◽

Solid Organ ◽

Initial Resuscitation

Background: In this ongoing era of 21st century, trauma is the leading cause of death in individuals between age 1 and 44. In trauma, also road traffic accidents (RTAs) are the major cause of death. Blunt abdominal trauma is a frequent emergency and is associated with significant morbidity and mortality.Methods: A prospective analysis of 50 patients of blunt abdominal trauma admitted in SMIMER hospital Surat within a span of 12 months was done. Unstable patients with initial resuscitation underwent focused assessment sonography for trauma (FAST). Failed resuscitation with free fluid in abdomen confirmed by FAST immediately shifted to operation theatre for laparotomy and proceed. Hemodynamically stable patients underwent computerized tomography of abdomen.Results: Most of the patients in our study were in the age group of 21-45 years with M:F ratio of 4:1. RTAs (62%) was the most common mechanism of injury. Spleen (38%) was the commonest organ injured and the most common surgery performed was splenectomy. In total non-operative management (NOM) was done in 58% of cases and surgical management was done in 42% of cases.Conclusions: Appropriate patient selection, early diagnosis and repeated clinical examination and use of appropriate investigations forms the key in management of blunt abdominal trauma. To conclude, initial resuscitation measures and correct diagnosis forms the most vital part of blunt abdominal trauma management.

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