Pediatric Abdominal Trauma Imaging
Pediatric Abdominal Trauma Imaging
Author: Kathryn E. Nuss, MD, FAAP, Assistant Professor of Clinical Pediatrics, Division of Emergency Medicine, The Ohio State University, Children’s Hospital, Columbus.
Peer Reviewer: Gary M. Vilke, MD, FACEP, FAAEM, Associate Professor of Clinical Medicine, Department of Emergency Medicine, University of California, San Diego Medical Center.
Injury is the most significant threat to the health of American children and the leading cause of death in children after the first year of life. Nearly 19,000 children and teenagers younger than age 20 died from injuries in 1997.1 While head and thoracic injuries account for the majority of incidences of death and disability in childhood, abdominal trauma is the leading cause of unrecognized fatal injury in children.2 Inadequate resuscitation still remains the leading cause of preventable death.3 Therefore, early detection and management of abdominal injuries has the most profound impact on survival rates. For this reason, physicians who care for the injured child must have a thorough understanding of the presentation, evaluation, and initial management of abdominal injuries in the pediatric patient. This issue will provide an overview of the mechanisms of intraabdominal injury (IAI) and a suggested management strategy for the injured child with a focus on the abdomen. The discussion also will include a review of the current literature regarding the radiolographic imaging studies available today to specifically evaluate pediatric blunt abdominal injuries.— The Editor
Mechanism of Injury
Unlike in adult trauma patients, the majority of abdominal injuries in children are due to blunt force. While isolated abdominal injury occurs in children, most abdominal injuries occur in the multisystem-injured patient. Abdominal trauma in children may occur as the result of motor vehicle, pedestrian, and bicycle accidents. Falls, sports injuries, and child abuse also account for a significant number of these injuries. All of these mechanisms are similar in that they produce blunt force to the abdomen. The energy is transferred through the abdominal wall to the intraabdominal organs, resulting predominately in injury to the solid organs, namely the liver and spleen. Parenchymal fracture and subcapsular hematoma may lead to hemorrhage. However, in the majority of pediatric patients, the bleeding stops spontaneously and allows for nonoperative management.4 Despite the frequency of self-limited solid organ injury in children, it is crucial to remember that massive hemorrhage, bladder rupture, hollow viscus perforation, and other life-threatening injuries do occur.
The physician caring for the injured child should approach each patient with a high index of suspicion for IAI. The assessment of the multisystem-injured trauma patient should begin with the ABCs: airway with cervical spine immobilization, breathing, and circulation. Priorities include confirmation of a protected airway and management of life-threatening injuries and shock. During the resuscitation phase, the abdomen is evaluated.
History of the circumstances surrounding the trauma should be delineated, as it can be helpful in the evaluation of abdominal injuries. The multisystem-injured child obviously is at risk for IAI; however, minor falls and direct blows to the abdomen from bicycle handlebars, balls, and bats may have sufficient energy to cause serious IAI. In cases involving motor vehicle crashes, it is helpful to know the extent of the vehicle damage as well as the type of restraints used, if any. A history of abdominal pain, tenderness, bruising, or vomiting of blood or bile necessitates a systematic diagnostic evaluation.
Non-accidental trauma (child abuse) should be suspected when the history is not consistent with the clinical presentation or extent of injury. The most common presentations of abdominal injury from abuse include shock, followed by peritonitis and vomiting. In most cases, there is a prolonged delay (mean 13 hours) before children with abuse-related blunt abdominal trauma are brought to the hospital.5 Mortality is extremely high (45%), owing to delays in presentation and the magnitude of the injuries.6
Evaluation of the Abdomen
A frightened child is difficult to examine. The majority of children with abdominal injuries also have significant injuries to the head and extremities that can obscure the often subtle physical findings associated with IAI. In addition, the physical exam findings may not be reliable in the fearful, agitated, or unconscious child. Vital signs, including blood pressure and pulse, frequently are normal for age in children with solid organ injury. As much as 30-40% of blood volume may be lost before hypotension results.7 The absence of bowel sounds is nonspecific and seldom distinguishes children who require operative management from those who do not. Tachycardia is a clinical finding that should prompt careful evaluation and frequent reassessment.
The entire trunk—anterior and posterior, including the flank areas—must be examined for lacerations, abrasions, ecchymoses, tenderness, penetrating wounds (including entry and exit sites), seatbelts marks, and tire tracks. Gentle palpation of the abdomen should be performed to recognize the signs of rebound tenderness. Abdominal distention may be due to peritonitis or hemoperitoneum, but most frequently results from swallowed air in the crying child. Early gastric decompression may be helpful to facilitate the abdominal examination and prevent vomiting and aspiration of gastric contents.
Most importantly, the key to recognizing a pediatric abdominal injury is a careful physical examination, repeated frequently, and serial assessments of vitals signs.
Laboratory Evaluation
The physical examination of a conscious, alert child is very helpful in the identification of abdominal pain, tenderness, or guarding. Bicycle handlebars, seatbelts, or focal trauma to the abdomen that result in bruising or contusions are markers of potential underlying injury. In a younger child or a patient with an altered mental status or other painful injuries, the physical examination of the abdomen is notoriously unreliable and inadequate for identifying IAIs.8 Therefore, reliable diagnostic adjuncts to physical examination are needed in the evaluation of blunt abdominal trauma in the injured child.
Laboratory tests may be useful in the evaluation of the pediatric trauma patient with abdominal injury. The recommended tests include a complete blood count, liver function tests, arterial blood gases, coagulation studies, serum amylase, type and crossmatch, and urinalysis.9 Initially, the hematocrit may be of little value, as there generally will not have been enough time for equilibration to have occurred. However, serial assessments of the hematocrit may provide a better clue to the initial extent of blood loss as well as ongoing losses. Elevations of the serum concentrations of the hepatic enzymes suggest liver injury. An elevated serum amylase may indicate an injury to the pancreas and possibly the spleen, which lies in close proximity to the tail of the pancreas.
In addition, urine should be collected and sent for urinalysis. The presence of hematuria is not only a marker of renal injury, but also of non-genitourinary abdominal injury. In one study of 378 children undergoing abdominal computerized tomography (CT) scan following blunt abdominal trauma, 66% were found to have hematuria (220 had microscopic hematuria and 36 had gross hematuria). The organs injured were spleen (11%) and liver (10%), whereas renal trauma occurred in only 8% of these children.10 In the 36 patients with gross hematuria, renal trauma was found in 22%, spleen injury in 17%, and liver injury in 8%. While the degree of hematuria correlated with a higher risk of abdominal injury, all children with hematuria had other clinical indications for CT scan. Hematuria may occur without gross renal injury following capillary disruption due to blunt force alone. Therefore, hematuria is an important marker of the magnitude of force associated with the blunt trauma, and its presence generally supports that an abdominal CT scan should be performed.10 Hematuria may indicate trauma of the genitourinary system at any location. On the other hand, the absence of hematuria does not rule out renal pedicle injuries.11,12
Controversy continues over the amount of hematuria that must be present to identify all renal injuries. In the past, radiologic evaluation was performed on all children with any degree of hematuria in the belief that this may be the only indicator of serious renal injury or of occult renal anomalies.13 A recent meta-analysis reviewed 12 studies of a total of 1048 children who underwent radiologic imaging following blunt abdominal trauma.14 In the children who had significant renal injuries, 32% had gross hematuria, 8% had 50 or more red blood cells per high power field (RBC/HPF) in their urine, and 2% had fewer than 50 RBC/HPF in their urine. Of note, all children with significant renal injuries and fewer than 50 RBC/HPF in their urine were seriously ill and had other clinical indications for abdominal CT scan. The authors concluded that renal imaging was indicated only in children with abdominal trauma, with another indication for abdominal CT scan, or with 50 or more RBC/HPF in their urinalysis. One study also concluded that a urinalysis with 50 or more RBC/HPF indicates a severe renal injury and that renal imaging is appropriate in this setting.15 This finding, however, was not confirmed in a recent retrospective study of 100 consecutive children with blunt renal trauma. In this study, 11 children with minor injuries and two of eight children with major injuries of the genitourinary tract had microscopic hematuria of fewer than 20 RBC/HPF.16 Furthermore, many authors still believe that radiographic imaging is required for all pediatric patients with any degree of hematuria after blunt abdominal trauma, even if they are hemodynamically stable.17,18
Several studies have questioned the usefulness of many of these laboratory tests in the setting of acute trauma. One study examined 3939 laboratory screening tests in 285 consecutive children with mild to moderate injury admitted to a pediatric trauma center, and 91 patients with proven IAI. Researchers found that abdominal examination combined with a urinalysis detected 98% of all abdominal injuries.19 The authors of this study concluded that ancillary testing rarely identifies unsuspected injuries in the awake, alert, and cooperative child with mild to moderate trauma. While laboratory determinations may help to substantiate the existence of an injury, it is important to recognize the limitations and value of the individual laboratory tests.
Diagnostic Peritoneal Lavage (DPL). DPL was first described more than 30 years ago as a technique to allow more definitive evaluation of blunt abdominal trauma.20 Since that time, it has been widely studied and has become a standard means of evaluating the abdomen for injury in adult patients following blunt trauma. Studies have found the sensitivity of DPL to range from 90% to 100%, with specificities of 73-100%.21 It is a useful diagnostic tool in adult trauma since adult abdominal injuries typically require operative care.
On the other hand, the management of solid organ injuries in children has changed during the last decade. Today, the emphasis is on nonoperative treatment for these types of injuries. Therefore, DPL rarely is used in the pediatric population because the presence of blood in the peritoneal cavity is not in itself an absolute indication for surgery. Furthermore, the DPL may be falsely positive in a significant number of children with blunt trauma, leading to an unnecessarily high laparotomy rate.22 In children requiring immediate surgical intervention for life-threatening head and thoracic injuries, DPL may be indicated to exclude abdominal trauma when no time exists to perform an abdominal CT scan.
Plain Radiographs. Plain radiographs of the cervical spine, chest, and abdomen typically are obtained during the course of the trauma evaluation. The initial supine radiographs may provide some clues to the diagnosis of IAI. There are some roentgenographic signs of solid organ injury in a child on a supine abdominal radiograph. For example, free blood in the peritoneal cavity may produce a ground-glass appearance and obscure normal soft-tissue silhouettes. Splenic injury should be suspected when left upper quadrant organs are displaced or when there is a left pleural effusion, atelectasis in the left lung base, or fractures of ribs 10-12 on the left side of the thorax. Liver injury may produce similar findings in the right upper quadrant of the abdomen. Free air may be seen on a supine film (Figure 1), but is viewed best on an upright chest film or lateral decubitus (Figure 2).
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Several authors continue to support the plain abdominal radiograph as a useful tool in the diagnosis of abdominal injury.23 However, in two studies by Rothrock et al, researchers found that abdominal radiographs were normal in greater than 95% of the cases and only served to delay definitive care.24,25 Of note, normal radiographs of the chest and abdomen do not rule out an IAI.
Computerized Axial Tomography. In 1980, researchers first reported the use of CT scan in the management of pediatric abdominal trauma.26 Since this time, the abdominal CT scan has been accepted as the diagnostic test of choice for blunt abdominal trauma in hemodynamically stable children. The advantages of CT scanning are that it can demonstrate specific organ injuries and determine the severity of liver, spleen, and kidney lacerations. (See Figures 3 and 4.) The CT scan also has the advantage of providing specific information about pelvic and retroperitoneal structures, in addition to its demonstrated sensitivity in identifying renal injuries.27 (See Figure 5.)
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Indications for abdominal CT scan include clinical suspicion of abdominal injury, the need for significant fluid resuscitation without obvious blood loss, the multisystem-injured patient, abdominal injury with hematuria, children with an altered mental status or an unreliable physical examination.
In a recently published study, 1500 consecutive children with blunt abdominal trauma were evaluated prospectively with an abdominal CT scan.28 Three hundred eighty-eight (26%) children had abnormal findings on CT scan. In the children who required laparotomy, all solid organ injuries were identified by CT scan and 96% of the hollow viscus injuries were diagnosed. Only one child with a normal CT scan later required laparotomy for a bowel injury. The authors concluded that CT findings affected the decision for operative intervention in most children with hollow viscus injury; however, CT findings rarely affected such a decision in a small subset of children with solid viscus injuries. They also found that normal abdominal CT scans strongly predicted a lack of subsequent deterioration requiring operative management. This series confirmed the usefulness of CT scan in identifying significant injuries to the liver, spleen, and kidneys. Other studies also support the use of CT scan in grading injury severity and estimating hematoma size to aid in predicting the need for surgical intervention.29,30
While solid organ injury from blunt abdominal trauma is much more common than hollow viscus and mesenteric injury, prompt diagnosis of these types of injuries is important because the management is surgical. A delay in diagnosis may result in an increased morbidity and possible mortality. Unfortunately, children with bowel injuries may have normal CT scans or CT scans with nonspecific findings. Literature exists both in support of and also to dispute the use of CT scan in this clinical setting. However, no consensus has been reached, and the use of CT scan to identify bowel injuries in blunt abdominal trauma remains controversial.
The difficulty in the diagnosis of blunt hollow viscus injury by abdominal CT scan is a combination of the limitations of CT technology and the lack of recognition of the subtle signs of this injury that may be present. In the misdiagnosis of blunt hollow viscus injury, misinterpretation of a true positive CT seems more common than a false negative CT scan.31
Several studies retrospectively have identified CT findings that suggest mesenteric or hollow viscus injury.32-34 These include bowel wall enhancement or thickening, pneumoperitoneum (See Figure 6), dilated loops of bowel, streaking of the mesenteric fat, and free peritoneal fluid in the absence of solid organ injury. (See Figure 7.) Despite these findings, the diagnosis of intestinal and mesenteric injuries continues to be difficult.
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In one study, 16 children underwent eventual exploration when they developed peritonitis; five had CT scans with signs of hollow viscus injury only when read retrospectively, and the remaining 11 had signs that were recognized but believed not to warrant immediate laparotomy.35 One group found that two intestinal injuries missed on abdominal CT scan had free air when read in retrospect. In addition, 60% of abdominal CT scans had free intraperitoneal fluid when read retrospectively, which were recognized initially but thought to be insignificant.36
The significance of free intraperioneal fluid found on abdominal CT scan is a topic of ongoing discussion both in the adult and pediatric trauma literature. Recent reports in the adult literature recommend mandatory laparotomy when CT scanning finds isolated intraperitoneal fluid without solid organ injury.37,38 These authors cite a high incidence of hollow viscus injury associated with free intraperitoneal fluid as the basis for their recommendations. This differs from the recent pediatric trauma literature.
In a recent study, the authors sought to determine if these same guidelines applied to children. Over a four-year period, there were 814 children admitted to their institution with blunt abdominal trauma; 437 had abdominal CT scans. Of these children, 32 had free intraperitoneal fluid without associated injuries and formed the basis of the study. Five of these children underwent laparotomy based on the CT finding alone. Only one of the five (20%) children had a therapeutic laparotomy. The remaining 27 children were observed with serial examinations and did not require operative management. During the same time period, 38 children underwent laparotomy after blunt trauma based on physical examination findings alone. The therapeutic laparotomy rate in this group was 68% and statistically was significant when compared to the other group, which underwent laparotomy based on CT findings alone. The investigators concluded that in contrast to adults, the finding of isolated free intraperitoneal fluid after blunt trauma does not necessitate immediate abdominal exploration.39
In another study, the authors conducted a prospective, observational study of consecutive children younger than 16 years old with blunt torso trauma who underwent abdominal CT scanning in the ED. The objective was to determine the frequency of isolated intraperitoneal fluid (IIF) on abdominal CT scan in pediatric blunt trauma patients and the association between IIF and associated clinically identifiable IAIs in these patients. Patients were considered to have IIF if the CT scan demonstrated intraperitoneal fluid without solid organ injury. Five hundred twenty-seven children with blunt trauma were enrolled in the study. Eighty-eight patients had intraperitoneal fluid on CT scan, and 42 of these patients had IIF. Of the 42 patients, five were discharged to home and were well at telephone follow-up. The other 37 patients were hospitalized. Of the 42 patients with IIF, seven patients had IAIs subsequently identified during their evaluations (all had gastrointestinal injuries). Six of the seven patients with IIF with subsequently identified IAIs had abdominal tenderness on physical examination in the emergency department. The authors concluded that patients with a small amount of IIF on CT scan, who lack abdominal tenderness, and who have a normal level of consciousness are at low risk for subsequently identified IAIs.40
Ultrasonography
Since the mid-1990s, ultrasound has had a promising role in the evaluation of blunt abdominal trauma. The focused assessment for the sonographic examination of the trauma patient, or FAST exam,41 has become the triage tool of choice in evaluating adult blunt trauma patients.42-45 The FAST examination evaluates up to six areas for hemoperitoneum. (See Figure 8.)
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These areas are the right upper quadrant, including Morison’s pouch; the right pleural space; the left upper quadrant and left pleural space; the subxiphoid area for pericardial fluid; the right and left paracolic gutters; and the pelvis or pouch of Douglas (retrovesical pouch). Of note, blood will accumulate in the most dependent portion of the upper abdomen (Morison’s pouch) in up to 97% of patients with spleen or liver lacerations.46 Many adult trauma studies conducted in the last several years have evaluated bedside ultrasound in an effort to determine the sensitivity and specificity in detecting hemoperitoneum. These studies have found ultrasound to be fairly sensitive (80-100%) and specific (88-100%) in detecting hemoperitoneum.47 On the contrary, many authors have found ultrasound to be not so reliable in identifying solid organ and hollow viscus injuries. However, because of its accuracy in identifying patients who may require surgical intervention, ultrasound has become the screening test of choice in many adult trauma centers.
Recently, several studies have evaluated the accuracy of bedside ultrasound in children with blunt abdominal trauma.48-50 Generally, these studies have found that ultrasound was less precise in detecting solid organ injuries, but it was helpful in children who required laparotomy by accurately identifying injuries with free intraperitoneal fluid. In one study, the authors found that the lack of free fluid on ultrasonography of the abdomen was not reliable to exclude IAI, since 34% of the children with injuries did not have free fluid.
The advantages of ultrasound are that it is safe, fast, noninvasive, inexpensive, and fairly accurate in identifying children requiring surgical intervention. However, children who remain hemodynamically unstable require laparotomy regardless of the ultrasound findings. On the other hand, the stable child with blunt abdominal trauma typically is managed nonoperatively. In this clinical setting, the CT scan provides more information about specific organ injuries and the severity of damage and is more useful in the management of these patients. Furthermore, most physicians caring for the injured child with blunt abdominal trauma generally accept that CT scan is better than ultrasound in detecting hollow viscus injuries and pancreatic injuries and for evaluating retroperitoneal structures.51 Therefore, ultrasound has little utility in the management of the pediatric blunt trauma patient.
Rational Approach to Evaluating Children with Abdominal Trauma in the ED
When a child presents to the ED with blunt abdominal trauma, the examining physician is faced with the challenge of prompt evaluation and management of the injuries. Figure 9 (click here) is a logical algorithm for the management of pediatric blunt abdominal trauma.
Conclusion
Blunt abdominal trauma is the most common cause of IAI in children. Serious injuries are relatively common. Recognition of abdominal injuries in the pediatric patient is especially challenging in the setting of multisystem trauma. For these reasons, the physician caring for the injured child must have a thorough understanding of the evaluation and management of IAIs sustained from blunt trauma.
As previously discussed, the physical examination of a frightened child with multiple injuries often is unreliable. Laboratory blood tests have little utility in the setting of acute trauma and only serve to support the presence of an injury.
Furthermore, DPL rarely is utilized in children and may be useful only in the context of a significant head injury requiring emergent craniotomy.
The radiographic evaluation of the child with blunt abdominal trauma includes plain radiographs, CT scan, and ultrasound. The stable child is best evaluated using abdominal CT scan. Bedside ultrasonography has little utility in the evaluation of pediatric blunt abdominal trauma.
In contrast to adult patients with blunt abdominal trauma, the management of children with solid organ injuries is predominantly nonoperative. For those children who exhibit ongoing hemodynamic instability or pneumoperitoneum, emergency laparotomy will be required.
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