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BioMed Central
Journal of Trauma Management &
Outcomes
ssOpen AcceReview
Free abdominal fluid without obvious solid organ injury upon CT
imaging: an actual problem or simply over-diagnosing?
Vanessa M Banz*1, Muhammad U Butt2, Heinz Zimmermann3, Victor Jeger3
and Aristomenis K Exadaktylos3
Address: 1Visceral Surgery and Medicine, Inselspital, Berne, University Hospital and University of Berne, Switzerland, 2Trauma, Emergency Surgery,
Surgical Critical Care, MGH, Harvard Medical School, Boston, Massachusetts, USA and 3Academic Emergency Medicine, Inselspital, Berne,
University Hospital and University of Berne, Switzerland
Email: Vanessa M Banz* - vanessa.banz@insel.ch; Muhammad U Butt - umarbutt177@gmail.com;
Heinz Zimmermann - victor.jeger@students.unibe.ch; Victor Jeger - heinz.zimmermann@insel.ch;
Aristomenis K Exadaktylos - exadaktylos@exadaktylos.ch
* Corresponding author
Abstract
Whereas a non-operative approach for hemodynamically stable patients with free intraabdominal
fluid in the presence of solid organ injury is generally accepted, the presence of free fluid in the
abdomen without evidence of solid organ injury not only presents a challenge for the treating
emergency physician but also for the surgeon in charge. Despite recent advances in imaging
modalities, with multi-detector computed tomography (CT) (with or without contrast agent)
usually the imaging method of choice, diagnosis and interpretation of the results remains difficult.
While some studies conclude that CT is highly accurate and relatively specific at diagnosing
mesenteric and hollow viscus injury, others studies deem CT to be unreliable. These differences
may in part be due to the experience and the interpretation of the radiologist and/or the treating
physician or surgeon.
A search of the literature has made it apparent that there is no straightforward answer to the
question what to do with patients with free intraabdominal fluid on CT scanning but without signs
of solid organ injury. In hemodynamically unstable patients, free intraabdominal fluid in the absence
of solid organ injury usually mandates immediate surgical intervention. For patients with blunt
abdominal trauma and more than just a trace of free intraabdominal fluid or for patients with signs
of peritonitis, the threshold for a surgical exploration - preferably by a laparoscopic approach should be low. Based on the available information, we aim to provide the reader with an overview
of the current literature with specific emphasis on diagnostic and therapeutic approaches to this
problem and suggest a possible algorithm, which might help with the adequate treatment of such
patients.
Published: 15 December 2009
Journal of Trauma Management & Outcomes 2009, 3:10 doi:10.1186/1752-2897-3-10
Received: 1 July 2009
Accepted: 15 December 2009
This article is available from: http://www.traumamanagement.org/content/3/1/10
© 2009 Banz et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8
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Journal of Trauma Management & Outcomes 2009, 3:10 http://www.traumamanagement.org/content/3/1/10Review
The introduction of routine computed tomography (CT)
in trauma exposes us to a plethora of new information,
sometimes leaving us with more information than we had
bargained for. Although a recent study by Huber-Wagner
and colleagues was able to show a positive effect on overall survival of trauma patients with blunt injury receiving
whole-body CT during emergency department resuscitation [1], the study does not specifically evaluate abdominal trauma and free intraabdominal fluid without solid
organ injury. The question as to what to do with this subgroup of patients remains a matter of debate.
Whilst sonography and conventional radiography remain
well-established techniques, CT scanning of the abdomen
and pelvis is the procedure of choice to evaluate the
hemodynamically stable patient who has sustained blunt
or penetrating trauma. CT has replaced Diagnostic Peritoneal Lavage (DPL) as the first method of choice in many
trauma centers worldwide. Its major advantage is that it is
not only capable of revealing the presence of intraabdominal or intra-thoracic hemorrhage but can to some
extent also identify the organ involved [2].
CT exhibits very high sensitivity and specificity in detecting the majority of solid organ injuries, but unfortunately
misses up to 15% of small bowel and mesenteric injuries
as well as some acute pancreatic injuries [3,4]. Protocols
including a short delay between intravenous contrast
administration and actual CT imaging aim to improve
diagnostic accuracy in blunt abdominal trauma [5].
Although patients with solid organ injury may benefit
from this strategy, patients with free fluid as only visible
intraabdominal pathology or patients with suspected viscus injury did not profit from this diagnostic strategy.
Various authors have evaluated the benefits (or disadvantages) of the addition of contrast agent for CT scanning.
Older studies usually base their protocols on conventional or single-detector row helical CT scan with use of
oral and intravenous contrast. Although relatively rare
and not always easy to detect [6], extravasation of oral
contrast is highly specific for damage to the bowel and
nearly always results in further surgical exploration. Those
opposing the use of oral contrast argue the potential delay
in patient care and the risk of aspiration [7], which
although relatively uncommon [8], can end disastrous for
the patient. Newer studies using (multi-detector) CT scanners in which oral contrast was omitted show comparable
results [9,10], indicating, that administration of oral contrast can be avoided.
In centers where a CT scan is not available or limited to
office hours, frequent re-evaluation of the patient's condi
tion, repeated sonography and DPL remain the cornerstones of the diagnostic work-up of abdominal trauma. In
the setting where clinical evaluation alone is relied on to
determine whether or not a patient requires surgery, negative laparotomy rates may be up to 40% [11]. In centers
where a positive DPL is regarded as the gold standard
when deciding on an intervention, diagnostic laparoscopies or laparotomies are performed routinely. The downside of this strategy is a potentially high number of
unnecessary or non-therapeutic operations [12], its unreliability in detecting retroperitoneal injuries [13] and, if
performed too soon after initial trauma, can miss intestinal perforation [14].
Where CT scanning is readily available, up to 85% of
abdominal solid organ injuries are treated conservatively
[15]. Fortunately, the majority of these patients have
direct or indirect signs of organ damage, which guide the
trauma surgeon through the jungle of different decision
pathways [16]. Even in patients with gun shot wounds to
the abdomen, for whom operative management has, until
recently, been viewed as mandatory, abdominal CT scanning has proven itself to be a safe and useful method for
selecting patients for non-operative treatment [17-19]. In
general, there is no doubt that CT is extremely useful in
patients with suspected abdominal solid organ injuries.
Nowadays, a trauma surgeon's life without CT is inconceivable, especially for the new generation, trained in an
era when CT has always been available [20].
But what should be done if the "almighty CT scanner"
does not provide us with a conclusive answer to our questions? One of the most difficult diagnostic challenges is
the presence of free fluid in the abdomen without evidence of solid organ injury. In order to find an answer to
our question as to what should be done for patients in this
setting, we searched Pubmed for "free fluid (without)
solid organ injury".
The literature on this topic, which cites more than 50 publications in English alone - mostly retrospective reviews of
patient data - gives us an abundance of options to deal
with this dilemma. Recommendations vary from sole
observation with serial abdominal examinations, to further evaluation with additional radiological studies, DPL
and/or surgical intervention [21-28].
A major limitation of all the published studies is the inclusion of only a small number of full thickness hollow
organ injuries, which can be the source of the free abdominal fluid. In some studies, the number of patients with
blunt (abdominal) trauma presenting with free fluid but
without obvious organ injury is as low as 0.5%, especially
if the study population has a high ratio of male patients,Page 2 of 8
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Journal of Trauma Management & Outcomes 2009, 3:10 http://www.traumamanagement.org/content/3/1/10which is often the case in trauma patients [22]. The low
incidence of such injuries may be one reason why no randomized prospective controlled trials have been performed.
One of the largest systematic reviews, conducted by Rodriguez and co-workers, found 10 articles in which isolated
free abdominal fluid was seen without organ injury [21].
The study included 463 patients out of a total of 16000
(2.8%) with signs of free intra-abdominal fluid without
obvious solid organ injury who had received a CT scan for
blunt abdominal trauma. A therapeutic laparotomy was
performed in only 122 patients and the authors concluded that laparotomy is not warranted if the patient is
alert and can be monitored with repeated physical examination.
Although the preferred surgical access still is mainly via
quick and easy laparotomy, diagnostic laparoscopy, especially in the more stable patient, provides all the advantages of minimally invasive elective surgery. A recent study
from Cherkasov and coauthors, although retrospective,
was able to demonstrate the advantages of the less traumatic, safe and feasible technique of video-assisted minimally invasive surgery [29].
In a more recent single centre review of 2651 trauma
admissions, 14 (0.5%) patients had free intraabdominal
fluid without solid organ injury in the initial CT scan [22].
Eleven of these 14 patients underwent therapeutic
laparotomy based on the presence of hypotension, peritoneal irritation or additional findings on CT associated
with non-solid organ injury. In their discussion, Yegiants
et al. stressed that the decision on whether to operate or
not is made too often by solely relying on the surgeon's
personal experience - with the amount of free fluid
detected rarely playing a role [22].
Some authors suggest that traces of free fluid in the pelvis,
even so for male patients, with no other signs of injury are
not associated with significant intra-abdominal injury
and can be safely managed non-operatively [24]. The presence of more than "just a trace" is rare, but is a significant
indicator of intra-abdominal injury [24].
Others, like Malhotra and colleagues, concentrate their
evaluation more on the number of additional positive
findings, rather than the actual amount of free fluid,
which can be used to increase the accuracy of the CT scan
[27]. In a series of 8112 scans, they found only seven
patients with false negative scans. In addition to free fluid
signs of a pneumoperitoneum, mesenteric streaking,
thickened bowel wall and extravasation of contrast material were associated with hollow viscus injuries. Once
again, the small number of patients included with free
abdominal fluid without solid organ injury limits the conclusions of this study.
Whilst surgically important bowel and/or mesenteric injuries are usually accurately revealed using multi-detector
CT imaging [30], these injuries are not always associated
with extraluminal contrast material, abrupt termination
of mesenteric vessels or even contrast extravasation from
the mesenteric vessels. In such a setting even larger injuries can be initially missed. Unfortunately, missed intraabdominal hollow organ injuries have a high morbidity,
with mortality reaching 31% if undiagnosed for more
than 24 hours [31-33].
Even improvements in diagnostic equipment, such as
contrast-enhanced ultrasound or new generation multidetector CT scanners, have not been able to prove their
efficacy yet. Both ultrasound and CT-based diagnostic
algorithms have been proposed, but unfortunately hollow
viscus injuries can be missed by both radiological examinations. Neither repeated clinical follow-up nor repetitive
CT scan imaging revealed hollow viscus injury in the case
series of Permentier et al. [33]. The authors were disappointed by the possibilities of modern imaging technology and suggest traditional DPL, accompanied by the
determination of the cell count ratio, to reveal any injuries
at an early stage. In hemodynamically stable patients, DPL
should incorporate analysis of the cell count ratio, amylase and alkaline phosphatase levels and the presence of
food fibers or bile. In hemodynamically unstable patients,
explorative surgery should be carried out, as this usually
suggests damage to vascular structures rather than rupture
of a hollow viscus [33]. Otomo et al. and Hennemann et
al. have tried to refine the criteria for positive DPL [34,35].
The ratio of white blood cells (WBC) to red blood cells
(RBC) can be used, where a ratio of WBC:RBC 1: 150 is
regarded as being a positive finding [34]. Hennemann
corrects the WBC in the lavage fluid for the WBC in the
peripheral blood [35]. Unfortunately, both studies lack
the statistical evidence required to make DPL a valid tool
in the setting of abdominal trauma with evidence of free
fluid and without obvious solid organ injury. Another
hailed imaging tool, ultrasound, has also failed as the
diagnostic method of choice. Hollow viscus injuries do
not tend to bleed extensively so unless large volumes of
fluid have leaked out of, for example due to a larger perforation of the bowel, positive predictive values remain
very low (38%) [36]. CT has proven to be equally unreliable in this setting with a sensitivity ranging between 0%
and 85% [37]. Even combinations of additional positive
predictive signs, such as the presence of a pneumoperitoneum and visceral organ wall thickening, are not able to
increase CT sensitivity and specificity beyond 80%. The
only obvious sign of a hollow organ perforation remains
extravasation of oral contrast [38,39].Page 3 of 8
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Journal of Trauma Management & Outcomes 2009, 3:10 http://www.traumamanagement.org/content/3/1/10In alert and non-comatose patient, physical examination
(presence of peritonitis) is the method of choice to rule
out significant abdominal injury. However, signs of peritonitis may take hours before becoming clinically evident,
which is an important downside of this strategy. If the
patient is intubated, intoxicated or suffers from impaired
neurological function (e.g. tetraplegia), any clinical examination loses its value and the decision to carry out a surgical intervention (or not) based solely on clinical
findings becomes unreliable [40,41]. In his series of 90
patients with free intraabdominal fluid but without solid
organ injury, Livingston showed that 19% of patients
without abdominal tenderness actually had an abdominal injury [40]. One indirect sign, which seems to be associated with hollow organ injury (if free fluid without solid
organ injury is found) are seat belt marks, which increase
the likelihood of an abdominal injury 2- to 4-fold [42,43].
In a study by Chandler et al., 117 victims involved in a
motor vehicle accident were evaluated for the use of seatbelts and the presence or absence of a seatbelt mark [42].
14 of 117 (12%) patients had a seatbelt sign. Three of
these patients (21%) had a small bowel perforation. In
contrast, in the group of 103 patients without a seatbelt
sign, only two (1.9%) patients had small intestine perforation. The authors concluded that the presence of a seatbelt mark is associated with an increased likelihood of
abdominal and especially intestinal injuries and mandates a heightened level of suspicion [42].
In an older study, Appleby and co-workers investigated 36
patients with seatbelt marks who underwent laparotomy
after a motor vehicle accident [43]. A high incidence of
gastrointestinal injuries (67%) was noted in this group.
But again, the small sample size limits the value of this
study [43].
Summary
In accordance with the literature and to the best of our
knowledge, we suggest an algorithm (see figure 1 for
details), which involves asking oneself a few simple questions at the time-point of initial patient evaluation.
1. How hemodynamically stable is the patient?
2. How much fluid is present and where is the fluid
located?
3. How alert is the patient and how reliable is the clinical
examination?
4. Are there seat belt marks or other abdominal wall marks
indicating direct trauma to the abdomen?
5. Have we been able to read the CT scan correctly?
In the hemodynamically unstable patient, there is no
place for any academic discussions and the source of
bleeding should be sought aggressively. If there is eviThe algorithm summarizes a possible plan of action for patients who have sustained blunt abdominal injury with suspected intra bdominal injury other than solid organ damageFigure 1
The algorithm summarizes a possible plan of action for patients who have sustained blunt abdominal injury
with suspected intraabdominal injury other than solid organ damage. (A) Patient can be stabilized with adequate
fluid management. (B) Depending on local skill and availability of theatre resources, laparoscopy is the preferred method of
choice. (C) Positive/negative physical examination: refers to clinical signs of peritonitis. (D) Small amounts of abdominal fluid,
especially in the female patient, may be physiological. Even in the absence of any clinical signs and abdominal marks, the patient
should be evaluated on a regular basis, as some injuries require a certain time to become clinically manifest. (E) The risk of
intraabdominal injury is greatly increased if abdominal marks (such as seat belt marks) are present. Special care needs to be
taken so as not to miss any changes in patient presentation.Page 4 of 8
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Journal of Trauma Management & Outcomes 2009, 3:10 http://www.traumamanagement.org/content/3/1/10
Page 5 of 8
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a-c. a) Schematic drawing of a transverse section of the abdominal cavity, depicting fluid (in red) in the Morison pouch on the right, between kidney (K) and he li (L) and on the left free fluid between the left ki ney and the spleen (S)Figure 2
a-c. a) Schematic drawing of a transverse section of the abdominal cavity, depicting fluid (in red) in the Morison pouch on the right, between kidney (K) and the liver (L) and on the left free fluid between the left kidney
and the spleen (S). b) Male anatomy, sagittal plane, with free fluid in the pouch of Douglas (in red) between the bladder (B)
and the rectum (R). Prostate gland (P). c) Female anatomy, sagittal plane, with free fluid in the pouch of Douglas (in red)
between the uterus (U) and the rectum (R). Bladder (B).
Journal of Trauma Management & Outcomes 2009, 3:10 http://www.traumamanagement.org/content/3/1/10dence of free intra-abdominal fluid and the patient is stable and not requiring urgent and immediate surgical
exploration of the abdomen, laparoscopy may be the
diagnostic method of choice.
The technique chosen (laparotomy versus laparoscopy)
obviously depends on the surgeon's experience and the
overall hospital culture. In Europe laparoscopy is considered the surgical technique of choice, although it has it
downsides [44]. It is expensive, stretching the theatre
after-hour resources to the limit and is unreliable in the
hands of the inexperienced surgeon. If used correctly
though, it provides a less traumatic option and reduces
possible complications associated with a large incision.
Whilst evaluating the patient we suggest distinguishing
between a trace (minimal fluid in one region), and larger
amounts of free fluid (also seen as fluid in multiple areas).
According to the literature, over 70% of patients will fall
into the first category, and conservative treatment of these
a-c. a) Rectouterine pouch (females) or rectovesical excavation (males), also known as the pouch of DouglasFigure 3
a-c. a) Rectouterine pouch (females) or rectovesical excavation (males), also known as the pouch of Douglas. In
females a tiny amount of free fluid is physiological, particularly after ovulation. B = Bladder. b) Hepatorenal recess (L = liver, K
= right kidney), also known as Morison's pouch. Already small amounts of fluid can be detected in this potential space and are
an indication of free intraabdominal fluid. c) Space between the spleen (S) and the left kidney (K). Fluid detected in this space
may be an indication of splenic trauma but is non-specific and can be due to any form of free intraabdominal collection (blood/
ascites/intestinal leakage).Page 6 of 8
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Journal of Trauma Management & Outcomes 2009, 3:10 http://www.traumamanagement.org/content/3/1/10patients is thought to be safe in the vast majority of cases
[23]. As might be expected, the pouches of Douglas and
Morrison are the two most common locations for free
fluid. No other inter-peritoneal location seems to be associated with organ injury [23]. See figures 2 and 3 for
details.
Question number five, whether or not the CT scan has
been interpreted correctly is probably the most challenging question to answer and problem to solve.
Conclusions
A thorough literature search has made it apparent that
there is no straightforward answer to the question of what
to do with patients with free fluid on CT scanning but
without signs of organ injury. All studies, whether they are
prospective or retrospective, lack the statistical power to
provide a definite answer. Furthermore, the studies are
difficult to compare, as there are significant differences in
imaging equipment, laboratory workup and surgical experience. The majority of the studies investigated inhomogeneous groups of patients or had methodological or
statistical problems.
Fortunately this type of injury is very rare. This in turn,
however means that exposure to such cases in the course
of one's career is infrequent, making it difficult to rely on
general experience alone to correctly diagnose and adequately treat such injuries.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
VB designed the study and drafted the manuscript, HZ
coordinated and helped to draft the manuscript, MB
helped conceive the study and contributed to the revisions, VJ helped revise the manuscript and designed Figures 2a-c. AE conceived of the study, participated in the
design of the study and helped to draft the manuscript. All
authors read and approved the final manuscript.
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