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

Abstract

BackgroundIn 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.AimThe 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.ResultsThe 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. ConclusionsThe 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.

A Retrospective Study of Blunt Trauma Abdomen

“…(18) High rate of operative complications caused paradigm shift from operative to non-operative management (NOM) in haemodynamically stable patient. (4) Liver due to its firm texture is more confidently treated by NOM.…”

First report of hepatic hematoma after presumed Bothrops envenomation

“…According to Van der Vlies et al (12) , the progress in imaging techniques has contributed to nonoperative management (NOM), currently considered the treatment of choice for hemodynamically stable patients after blunt injury to solid abdominal organs with hematoma. Angioembolization can be used as an adjunct to NOM and has increased the success rate (12) .…”

“…Surgical intervention is necessary only in cases of hemodynamic instability, progressive pain, and continued expansion of the hematoma (12) . A surgical approach could also be necessary if the patient had progressive worsening of coagulation parameters (12) . However, in this case, the aPTT remained stable and normalized 2 days after the accident (Table 1).…”

“…CT and magnetic resonance imaging are tools that yield more precise information than USG in the characterization of hemorrhagic collection (12) .…”

The role of multidetector computed tomography versus digital subtraction angiography in triaging care and management in abdominopelvic trauma

“…(4) In the appropriate clinical setting, a negative CT could reduce unnecessary invasive procedures, as it opens up the possibility of conservative nonoperative management. (5) In turn, detection of active haemorrhage allows for consideration of digital subtraction angiography (DSA; with or without embolisation) and/or operative management. (6,7) Several recent studies have focused on the use of multiphasic acquisitions, in addition to the routine portal venous (PV) phase, for more accurate diagnosis; these include CT angiography (arterial phase) and delayed phase imaging.…”