Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs

Abstract

Background: In recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization.

Aim: The purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney.

Conclusions: The management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey. The progress in imaging techniques has contributed to NOM being currently the treatment of choice for hemodynamically stable patients. Angioembolization can be used as an adjunct to NOM and has increased the success rate to 95%. However, to date many controversies exist about the optimum patient selection for NOM, the proper role of angioembolization in NOM, the best technique and material to use in angioembolization, and the right follow-up strategy of patients sustaining blunt abdominal injury. Conducting a well-designed prospective clinical trial or a Delphi study would be preferable.

Figure 1

Diagnostic algorithm of patients with blunt abdominal injury.

Figure 2

Computed tomography with intravenous contrast shows small amounts of hemoperitoneum around the spleen and a contrast 'blush' confined to the splenic parenchyma.

Figure 3

Liver injury with intraperitoneal contrast extravasation visible on computed tomography scan.

Figure 4

Computed tomography with intravenous contrast showing hemoperitoneum, a fractured spleen with large hematoma and extravasation of contrast medium into the abdominal cavity.

Figure 5

Computed tomography with intravenous contrast demonstrating large hematoma around the right kidney with contrast extravasation.

Figure 6

Selective digital subtraction angiogram of the celiac axis showing the intra-peritoneal contrast 'blush' in the spleen, confirming active bleeding.

Figure 7

Selective splenic angiogram immediately post proximal embolization demonstrating perfusion defects. Contrast extravasation is no longer present.

Figure 8

Computed tomography with intravenous contrast: transection of the renal artery without contrast in the left kidney.

Figure 9

Angiogram of the same patient as in Figure 5 after recanalization and placement of a stent in the renal artery, resulting in good perfusion of the kidney.