Dilemmas in the diagnosis of blunt enteric trauma

Early identification of enteric injuries following blunt trauma relies on clinical examination, diagnostic peritoneal lavage (DPL), and/or computed tomography (CT) scan. Limitations in each approach may result in diagnostic delays and potentially increased complications. The purpose of this study was to evaluate the ability of early DPL and CT scans in identifying enteric injuries requiring surgical repair and to determine the impact of injury time to definitive repair on complication rates. A retrospective review of patients admitted to the Butterworth Hospital Level I Trauma Center between January 1,1990 and December 31, 1996 identified 69 appropriate patients. Three study groups were treated as follows: laparotomy on clinical examination (N = 7), laparotomy after initial DPL (N = 28), and laparotomy after initial CT (N = 34). Early DPL missed 5 (18%) enteric injuries, which was significantly fewer than the 13 (38%) missed by CT scan. Review of these 13 CT scans revealed 6 examinations not suggesting enteric injury and 7 with signs suggestive of injury. Four injuries missed by CT subsequently were found by delayed DPL. Morbidity rates in either group increased when injury time to definitive repair was >24 hours (18-50%). The results indicate that early DPL and CT have limitations in blunt enteric injuries. However, morbidity and mortality rates did not increase until repair was delayed >24 hours postinjury. Also, delayed DPL successfully identified these injuries in four patients after negative CT. Therefore, in patients at high risk for enteric injuries, there may be a role for delayed or repeat DPL after an initially negative DPL or CT.