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(Radiology. 1999;211:399-403.)
© RSNA, 1999

Emergency Radiology

Bowel and Mesenteric Injury: Evaluation with Emergency Abdominal US1

John R. Richards, MD, John P. McGahan, MD, Jamie L. Simpson and Payam Tabar

1 From the Division of Emergency Medicine (J.R.R., J.L.S., P.T.) and the Department of Radiology (J.P.M.), University of California, Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817. From the 1998 RSNA scientific assembly. Received June 5, 1998; revision requested July 27; revision received August 24; accepted October 13. Address reprint requests to J.R.R.


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To assess emergency ultrasonography (US) for detection of bowel and mesenteric injury from blunt trauma.

MATERIALS AND METHODS: For 3 years, prospective data on all patients undergoing emergency US were recorded. Patients with bowel and mesenteric injury were identified, and physical examination, laboratory, computed tomographic (CT), and intraoperative findings were compared with prospective data.

RESULTS: From January 1995 to January 1998, emergency US was performed in 1,686 patients; 71 patients had bowel and mesenteric injury. Forty-one examinations were true-positive (ie, with free fluid), and 30 were false-negative. Twenty-five of the 41 patients with true-positive US results had concomitant injuries that may have accounted for the free fluid, including liver, spleen, pancreas, gallbladder, kidney, and/or bladder injuries. The remaining 16 patients had isolated bowel and mesenteric injury. Bowel and mesenteric damage was identified intraoperatively in 70 patients. Twenty-nine of 30 patients with false-negative US examinations had abdominal tenderness. Sixteen patients with false-negative US results had bowel and mesenteric injury that was detected 12 or more hours after initial scanning.

CONCLUSION: Free fluid in the abdomen is not detected in the majority of patients with isolated bowel and mesenteric injury. For clinical suspicion of bowel and mesenteric injury, observation, serial physical abdominal examination, and CT may be helpful in diagnosing this condition.

Index terms: Abdomen, CT, 78.12112, 79.12112 • Abdomen, injuries, 78.411, 78.412, 79.411, 79.412 • Abdomen, US, 78.1298, 79.1298 • Pelvis, CT, 875.12112


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
The frequency of intraabdominal injuries from blunt trauma continues to increase worldwide (1–5). At our institution, bowel and mesenteric injuries represent a substantial portion of the total number of intraabdominal injuries; they have approximated 20% over the past 5 years. Historically, these injuries have been difficult to detect initially, and delayed diagnosis causes increased length of hospitalization, morbidity, and mortality (6–9). The signs and symptoms of bowel injury usually develop with time (7). Physical examination has been demonstrated to have variable use in the detection of intraabdominal injuries (10,11). Diagnostic peritoneal lavage is sensitive in the detection of some bowel and mesenteric injuries that result in hemoperitoneum, but it is less useful for identifying injuries that involve the retroperitoneum, such as descending colon or duodenal injuries (12–15). Diagnostic peritoneal lavage is also inappropriate for stable, alert trauma patients, who represent the majority of patients who present to the emergency department. Reliance on the nonspecific findings of diagnostic peritoneal lavage has been found to lead to a higher number of nontherapeutic laparotomies, with associated perioperative morbidity (16).

Computed tomography (CT) of the abdomen can demonstrate bowel and mesenteric injury when certain findings such as free fluid, pneumoperitoneum, a thickened bowel wall, and mesenteric infiltration are present (17–19). However, CT is not always reliable in enabling the diagnosis of isolated bowel and mesenteric injury. A minority of patients with intestinal perforation from blunt trauma have pneumoperitoneum on radiographs or CT scans (20–23). Many bowel and mesenteric injuries are localized intraoperatively, and these injuries are most often associated with injury to other organs such as the spleen and liver. Ultrasonography (US) is becoming the initial imaging study of choice for blunt abdominal trauma because it is rapid, noninvasive, and relatively inexpensive (24–30). To our knowledge, no previous study has specifically addressed the use of abdominal US in detecting bowel and mesenteric injury. We conducted this study to evaluate the use of emergency US for the detection of acute bowel and mesenteric injury in patients with blunt abdominal trauma.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
During a 3-year period, from January 1995 to January 1998, 1,686 emergency US examinations were performed for the sole purpose of detecting intraabdominal injuries in patients who had experienced blunt trauma. A total of 71 patients (39 male patients, 32 female patients; age range, 1–80 years; mean age [± SD], 31.9 years ± 17.4) were retrospectively identified as having bowel and mesenteric injury. The most common mechanism of injury was motor vehicle accident (n = 60), followed by automobile versus pedestrian accident (n = 4), motorcycle accident (n = 3), assault (n = 2), fall (n = 1), and blast (n = 1). Sixty-nine of the 71 patients had abdominal tenderness, 21 had a right rib fracture, and 20 had a left rib fracture.

This prospective study was performed at a large urban university hospital that serves as a level I trauma center for central and northern California. All patients who presented with blunt abdominal trauma were considered to be candidates for the study. This study was approved by the hospital's institutional review board, and informed consent (written or oral) was obtained from all stable, conscious patients prior to each examination. Rapid transabdominal US examinations were performed by registered diagnostic medical sonographers from the Department of Radiology by using a model XP10-128 (Acuson, Mountain View, Calif) or Imaging 5200S (Acoustic Imaging, Phoenix, Ariz) US unit and phased-array or convex 2.5–5.0-MHz transducers. This examination was performed as soon as possible after the patient arrived in the emergency department. The images were initially interpreted by the on-call faculty, fellow, or resident radiologist (J.P.M.), who also completed a data sheet detailing the findings. All images were recorded on film hard copy and reviewed immediately. All examination findings were recorded for final interpretation by faculty radiologists (J.P.M.). No discrepancies between preliminary and final report results were identified.

The patients with bowel and mesenteric injury were retrospectively identified, and their findings were compared with the results on the prospective data sheets completed by the interpreting physician. Final reports were obtained for all patients who underwent CT scanning or surgical intervention. The exact location and severity of the bowel and mesenteric injury in each patient was recorded. Grading of injury was performed by using guidelines set by the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (31). The presence or absence of abdominal tenderness at palpation from the documented physical examination was noted. Results of pertinent laboratory and other radiographic examinations were reviewed. The patients were followed up until their discharge from the hospital, and data on return visits to the emergency department and trauma clinic were obtained from chart review.

The left and right upper parts of the abdomen were scanned for the presence of free fluid, with attention to the splenorenal and hepatorenal interface. The liver parenchyma and spleen parenchyma also were evaluated to detect irregularities suggestive of hematomas, lacerations, or both. The epigastrium was scanned to evaluate the left lobe of the liver and the pancreas. Both the right and left flanks were scanned to detect free fluid and evaluate the retroperitoneum. The pelvis was evaluated for free fluid; however, this US examination was frequently performed without the aid of a full bladder. US features of actual bowel and mesenteric injury, such as bowel wall thickening or dilated loops, were not specifically looked for in this study. All US examinations were performed before CT, which was performed in 23 patients; diagnostic peritoneal lavage, which was performed in two patients; and laparotomy, which was performed in 70 patients. The US image was considered to be true-positive when free fluid was detected. Free fluid was assumed to represent hemoperitoneum, and irregularities within the parenchyma of solid organs or subcapsular collections of fluid were assumed to be lacerations or hematomas.

CT was performed with a model 900S (Toshiba, Tustin, Calif) or model 9800 HiSpeed Advantage (GE Medical Systems, Milwaukee, Wis) imaging unit. All scanning was performed by using intravenously administered iothalamate meglumine (Conray 60; Mallinckrodt, St Louis, Mo), with 1-cm incremental scans obtained from the diaphragm to the pelvis. Oral contrast material was not used to obtain trauma CT scans. All CT scans were read by faculty radiologists (J.P.M.) without knowledge of the US results. A positive diagnostic peritoneal lavage specimen was defined as an aspirate that demonstrated 10 mL of gross blood, a red blood cell count of greater than .0001 cells x 1012/L, or a white blood cell count of greater than .0005 cells x 109/L. The mean urine red blood cell count for the 71 patients was 99.8 cells per high power field ± 212.1.

Comparisons between groups were performed with the Student t test, Fisher exact test, and Mann-Whitney U test for nonparametric data. Data are reported as the mean (± SD) unless otherwise stated. Statistical significance was assumed at a level of P less than or equal to .05.


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Emergency US demonstrated free fluid (ie, was true-positive) in 41 (58%) patients and no free fluid (ie, was false-negative) in the remaining 30 (42%) patients. An example of free fluid in the pelvis at US, with CT correlation, is shown in Figure 1. Thirty-six (51%) patients had isolated bowel and mesenteric injury; the remaining 35 (49%) patients had concomitant injuries to the liver (n = 21), spleen (n = 20), pancreas (n = 7), kidney (n = 4), and bladder (n = 2). Twenty-five of the 41 patients who had true-positive US findings had concomitant injuries, which may have accounted for the free fluid. Sixteen patients had isolated bowel and mesenteric injury and true-positive US findings; in all of these patients, the damage to the bowel and mesentery was identified intraoperatively. Twenty of the 30 patients with false-negative US findings had isolated bowel and mesenteric injury. All except one of these 30 patients had abdominal tenderness.



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  		Figure 1a. Ascending colon laceration. (a) B = bladder, FL = fluid. Transverse US scan of the pelvis demonstrates a small amount of free fluid in the rectouterine pouch. (b) CT abdominal scan demonstrates thickening of the lower ascending colon (arrows). (c) CT scan of the pelvis demonstrates fluid in the rectouterine pouch (arrow), with loops of bowel anteriorly.

 


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  		Figure 1b. Ascending colon laceration. (a) B = bladder, FL = fluid. Transverse US scan of the pelvis demonstrates a small amount of free fluid in the rectouterine pouch. (b) CT abdominal scan demonstrates thickening of the lower ascending colon (arrows). (c) CT scan of the pelvis demonstrates fluid in the rectouterine pouch (arrow), with loops of bowel anteriorly.

 


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  		Figure 1c. Ascending colon laceration. (a) B = bladder, FL = fluid. Transverse US scan of the pelvis demonstrates a small amount of free fluid in the rectouterine pouch. (b) CT abdominal scan demonstrates thickening of the lower ascending colon (arrows). (c) CT scan of the pelvis demonstrates fluid in the rectouterine pouch (arrow), with loops of bowel anteriorly.

 
There were 34 small-bowel injuries; those of the jejunum were most common (Table 1). There were 52 large-bowel injuries; those of the ascending colon were most common. In Figure 2, free fluid associated with injury to the ileum is shown. Seventeen patients had both small- and large-bowel injuries. In 70 (99%) patients, the injuries were confirmed at exploratory laparotomy. The remaining patient had pneumoperitoneum, which was demonstrated at CT (Fig 3), but at further investigation, the upper gastrointestinal examination yielded a negative result. It was believed that this patient had a small perforation that sealed, and nonoperative management was chosen. One patient underwent repeat US in the emergency department. The second US scan obtained 2 hours after the first examination was positive for free fluid in the patient, who had a concomitant liver laceration.


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  		TABLE 1. Distribution and Severity of Bowel and Mesenteric Injuries
 


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  		Figure 2. H = liver, R = kidney. Mesenteric avulsion in the distal ileum. Longitudinal US scan demonstrates a small amount of free fluid in the hepatorenal fossa (arrow).

 


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  		Figure 3. Jejunal perforation and pneumoperitoneum. CT abdominal scan demonstrates free air just beneath the anterior abdominal wall (arrow).

 
Of the 30 patients with false-negative emergency US findings, 16 had bowel and mesenteric injury that was detected more than 12 hours after the initial US scanning in the emergency department. The injuries in all 16 patients were identified by the development or worsening of abdominal tenderness; four of these 16 patients had false-negative CT scans. The bowel and mesenteric injuries in the remaining 14 patients with false-negative US findings were identified by using CT in 11 patients and diagnostic peritoneal lavage in two patients, and by worsening hypotension with abdominal distention in one patient, who was taken directly to the operating room. All except one of the 30 patients (97%) with false-negative emergency US findings had abdominal tenderness.

The sensitivity of emergency US for the detection of bowel and mesenteric injury in the entire study group was 58% (41 of 71 patients; 95% CI, 45%, 69%). In only those patients with isolated bowel and mesenteric injury, the sensitivity was 44% (16 of 36 patients; 95% CI, 28%, 62%). To assess the difference in sensitivity between immediate and delayed manifestation of bowel and mesenteric injury, patients with bowel and mesenteric injury were divided into two groups. When the 16 patients with bowel and mesenteric injury that was detected more than 12 hours after the initial US scanning were omitted from the false-negative US group, the sensitivity increased to 75% (41 of 55 patients; 95% CI, 62%, 87%). We did not report all of the true-negative emergency US findings in the entire study population and thus were unable to determine specificity and negative predictive values. Patients with true-positive and false-negative US findings were compared. Among the patients with isolated bowel and mesenteric injury, those who had positive US scans had significantly higher injury grades than did those who had negative US scans (Table 2).


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  		TABLE 2. Comparison of Patients with True-Positive and False-Negative US Findings
 
A total of 23 CT examinations were performed in the 71 patients. Sixteen of these examinations were true-positive, one was false-positive, and six were false-negative for the detection of bowel and mesenteric injury. Fifteen patients who underwent CT had isolated bowel and mesenteric injury; CT helped to identify the bowel and mesenteric injury in 12 of these patients. The CT findings in these 12 patients were as follows: free fluid in five patients, pneumoperitoneum in four patients, hematoma in two patients, thickened wall in one patient, and dilated loop in one patient. The CT finding of wall thickening in bowel and mesenteric injury is shown in Figure 4. The sensitivity of CT in the detection of bowel and mesenteric injury was 80% (12 of 15 patients; 95% CI, 67%, 93%). The remaining four true-positive CT scans showed injury to other organs, with the bowel and mesenteric injury discovered intraoperatively. Free fluid was not identified on these four CT scans. In the detection of intraabdominal injuries, CT had a sensitivity of 73% (16 of 22 patients; 95% CI, 51%, 89%). There were no delayed manifestations of bowel and mesenteric injury or other intraabdominal injuries noted in the chart review of follow-up visits to the emergency department or trauma clinic after discharge from the hospital.



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  		Figure 4. Jejunal perforation. CT abdominal scan demonstrates small-bowel wall thickening (arrows) in the left upper part of the abdomen.

 

   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
Rapid limited transabdominal US is becoming a more common and accepted method of evaluating intraabdominal injuries in blunt trauma patients worldwide (27,29). Its sensitivity, compared with that of CT, has been reported in several studies (24–28). The use of US in detecting actual organ injury has been evaluated in few studies, and, to our knowledge, it has not been exclusively evaluated for bowel and mesenteric injury in any. McGahan and colleagues (25), in a series of 500 patients, identified three patients who had isolated bowel and mesenteric injury with free fluid that was identified at US. Hegenbarth et al (32) demonstrated free fluid and an echogenic mass in a patient with traumatic colon rupture. Rothlin et al (30) calculated the sensitivity of US to be 98% for identifying free fluid and 41% for identifying solid organ injury. Sherbourne and co-workers (33) identified a group of patients with visceral injury; 26% of these patients had no hemoperitoneum detected at screening US. In our study, there were no US abnormalities of the bowel or mesentery that were incidentally noted in the 71 patients with bowel and mesenteric injury. However, these subtle findings were not specifically searched for; only the presence of free fluid was evaluated.

In another study, Gruessner and colleagues (34) localized actual organ intraabdominal injuries in eight (23%) of 35 patients who underwent laparotomy. Goletti and co-workers (35) reported US to have a sensitivity of 73% for the localization of solid organ intraabdominal injuries, including 29 of 31 splenic injuries and eight of 10 hepatic injuries. The reference standard in our study was intraoperative findings, and in one case, CT findings. To remain consistent with previous studies, we chose the presence of free fluid to represent a true-positive US examination. Interestingly, this was also the most frequent CT finding (in five patients) in the detection of isolated bowel and mesenteric injury in our study.

The diagnosis of bowel and mesenteric injury has been notoriously difficult to establish rapidly in blunt trauma patients (1–8). Other imaging techniques, with the exception of US, have been evaluated specifically for detecting bowel and mesenteric injury. Because CT represents an alternative to US, it is interesting to note the results of past studies on CT and bowel and mesenteric injury. CT has had variable success in the detection of bowel and mesenteric injury in several studies (17–20), and the most common findings were free fluid and pneumoperitoneum. Other findings include thickened bowel wall, mesenteric hematoma, and dilated loops, but no single finding has been consistent (21-23). Mirvis et al (23) detected bowel and mesenteric injury prospectively in 15 (88%) of 17 patients who underwent laparotomy, and retrospective review, with attention to subtle findings, yielded a 100% detection rate with CT. Rizzo and colleagues (22) detected 26 (93%) bowel and mesenteric injuries in 28 patients by using CT; these injuries were confirmed later intraoperatively.

The subtle findings that are suggestive of bowel and mesenteric injury at CT were reviewed by Levine et al (20). The diagnostic clues in these findings included mesenteric abnormalities such as interloop fluid and fluid trapped between mesenteric leaves. In a similar study addressing this issue, Breen and colleagues (21) assessed the accuracy of various CT signs in the detection of bowel and mesenteric injury. Bowel wall thickening had a sensitivity of 50% and specificity of 84%, whereas pneumoperitoneum was 44% sensitive and 100% specific. In the Breen et al study (21), free fluid without solid-organ injury was present in 11 (58%) of 19 patients. In our study, oral contrast material was not routinely used, yet CT enabled the detection of bowel and mesenteric injury in 12 (80%) of 15 patients.

Bensard and co-workers (6) evaluated the importance of diagnostic delay in bowel and mesenteric injury in children and found the most reliable indicators were increased temperature, increased heart rate, and decreased urine output over 24 hours. Moss and Musemeche (11) confirmed that inpatient observation is the best method to detect occult bowel and mesenteric injury, and the presence of abdominal tenderness was 100% sensitive. Diagnostic peritoneal lavage was found to be the most sensitive indication of bowel and mesenteric injury in one study by Burney and colleagues (3). In that study, pneumoperitoneum was found on 16% of the plain radiographs. Microscopic hematuria has also been shown to be a marker of occult intraabdominal injury (36,37). In our study, we were unable to demonstrate any substantial difference in the amount of microscopic hematuria between patients with true-positive and those with false-negative US findings (Table 2). However, 56 (79%) of 71 patients did have microscopic hematuria.

Several series have noted a high frequency of solid-organ intraabdominal injuries and concomitant bowel and mesenteric injury, with the bowel and mesenteric injury often discovered incidentally at exploratory laparotomy (17–23). Trauma surgeons are aware of this correlation and routinely "run the bowel" to look specifically for bowel and mesenteric injury (1–4). Bowel and mesenteric injury remains very difficult to precisely localize by using any means (5). Physical examination results may be suggestive but are not reliable in differentiating bowel and mesenteric injury from other intraabdominal injuries (6,10,11). Similarly, CT findings of free fluid may be nonspecific, if even present. However, Levine and colleagues (20) reported pneumoperitoneum and bowel wall thickening to be specific for bowel and mesenteric injury. Finally, US can demonstrate free fluid in patients with bowel and mesenteric injury, but it is nonspecific and will not aid in the localization of the actual bowel and mesenteric injury (25).

Patients with substantial blunt trauma, abdominal tenderness, and a US scan positive for free fluid are often taken to the operating room. However, those with a negative initial US scan and continuing abdominal tenderness should undergo contrast material–enhanced CT of the abdomen. What about the use of repeat US after a defined period to detect the delayed manifestation of intraabdominal injuries? Siniluoto and colleagues (38) demonstrated the value of repeat US in patients who initially had a negative study for the depiction of splenic injuries. The likelihood of finding free fluid increases with time in the detection of bowel and mesenteric injury. The sonographer may have more time during repeat US to detect subtle abnormalities than during the initial US performed at resuscitation. Only one patient in our study underwent repeat US, which was positive for bowel and mesenteric injury. At this point, we cannot comment on the accuracy or use of repeat US in the detection of bowel and mesenteric injury.

We have found that worsening abdominal tenderness and delayed CT effectively helped to triage patients with bowel and mesenteric injury that was initially undetected on the basis of the absence of free fluid at US. For those patients with false-negative US and CT scans, observation, including serial abdominal examination and monitoring of vital sign changes and laboratory results, remains the only other method of detecting occult bowel and mesenteric injury (3,10,11,36).

In conclusion, bowel and mesenteric injury from blunt abdominal trauma is frequently associated with injury to other organs, and this may account for the findings of free fluid at US. Free fluid in the abdomen was detected in 44% of patients with isolated bowel and mesenteric injury in this study, and this may be a useful marker for triaging patients to the operating room. Bowel and mesenteric injury remains difficult to image, and at times, both US and CT fail in its detection. For suspected occult bowel and mesenteric injury, we recommend an initial US examination, which, if negative for free fluid, should be followed by serial abdominal examinations and CT.


   Footnotes
 
Author contributions: Guarantors of integrity of entire study, J.R.R., J.P.M.; study concepts and design, J.R.R., J.P.M.; definition of intellectual content, J.R.R., J.P.M.; literature research, J.R.R., J.P.M., J.L.S., P.T.; clinical studies, J.R.R., J.P.M.; data acquisition and analysis, J.R.R., J.P.M., J.L.S., P.T.; statistical analysis, J.R.R.; manuscript preparation, editing, and review, J.R.R., J.P.M., J.L.S., P.T.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Roman E, Silva YS, Lucas C. Management of blunt duodenal injury. Surg Gyn Obstet 1971; 132:7-14.
  2. Donohue JH, Crass RA, Trunkey D. The management of duodenal and other small intestinal injury. World J Surg 1985; 9:904-913.[Medline]
  3. Burney RE, Mueller GL, Coon GL, et al. Diagnosis of isolated small bowel injury following blunt abdominal trauma. Ann Emerg Med 1983; 12:71-74.[Medline]
  4. Robbs JV, Moore SW, Pillay SP. Blunt abdominal trauma with jejunal injury: a review. J Trauma 1980; 20:308-311.[Medline]
  5. Bloom AI, Rivkind A, Zamir G, et al. Blunt injury of the small intestine and mesentery: the trauma surgeon's Achilles heel?. Eur J Emerg Med 1996; 3:85-91.[Medline]
  6. Bensard DD, Beaver BL, Besner GE, Cooney DR. Small bowel injury in children after blunt abdominal trauma: is diagnostic delay important?. J Trauma 1996; 41:476-483.[Medline]
  7. Schimpl G, Schmidt B, Sauer H. Isolated bowel injury in blunt abdominal trauma in childhood. Eur J Pediatr Surg 1992; 2:341-344.[Medline]
  8. Fischer RP, Miller-Crotchett P, Reed RL. Gastrointestinal disruption: the hazard of nonoperative management in adults with blunt abdominal injury. J Trauma 1988; 28:1445-1449.[Medline]
  9. Phillips TF, Brotman S, Cleveland S, Cowley RA. Perforating injuries of the small bowel from blunt abdominal trauma. Ann Emerg Med 1983; 12:75-79.[Medline]
  10. Richards JR, Derlet RW. Computed tomography and blunt abdominal injury: patient selection based on examination, haematocrit and haematuria. Injury 1997; 28:181-185.[Medline]
  11. Moss RL, Musemeche CA. Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg 1996; 31:1178-1181.[Medline]
  12. Ryan JJ, Kyes FN, Horner WR, Young JC, Diamond DL. Critical analysis of open peritoneal lavage in blunt abdominal trauma. Am J Surg 1986; 15:221-223.
  13. Gomez GA, Alvarez R, Plasecia G, et al. Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment. J Trauma 1987; 27:1-5.[Medline]
  14. Kearney PA, Vahey T, Burney RE, Glazer G. Computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma: their combined role. Arch Surg 1989; 124:344-347.[Abstract]
  15. McKenney M, Lentz K, Nunez D, et al. Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma?. J Trauma 1994; 37:439-441.[Medline]
  16. Shah R, Max MH, Flint LM. Negative laparotomy: mortality and morbidity among 100 patients. Am Surg 1978; 44:150-154.[Medline]
  17. Peitzman AB, Makoroun MS, Slasky BS, Ritter P. Prospective study of computed tomography in initial management of blunt abdominal trauma. J Trauma 1986; 26:585-592.[Medline]
  18. Glazer GM, Buy JN, Mass AA, Goldberg HI, Federle MP. CT detection of duodenal perforation. AJR 1981; 137:333-336.[Free Full Text]
  19. Donohue JH, Federle MP, Griffiths BG, Trunkey DD. Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries. J Trauma 1987; 27:11-17.[Medline]
  20. Levine CD, Gonzales RN, Wachsberg RH, Ghanekar D. CT findings of bowel and mesenteric injury. J Comput Assist Tomogr 1997; 21:974-979.[Medline]
  21. Breen DJ, Janzen DL, Zwirewich CV, Nagy AG. Blunt bowel and mesenteric injury: diagnostic performance of CT signs. J Comput Assist Tomogr 1997; 21:706-712.[Medline]
  22. Rizzo MJ, Federle MP, Griffiths BG. Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT. Radiology 1989; 173:143-148.[Abstract/Free Full Text]
  23. Mirvis SE, Gens DR, Shanmuganathan K. Rupture of the bowel after blunt abdominal trauma: diagnosis with CT. AJR 1992; 159:1217-1223.[Abstract/Free Full Text]
  24. Pearl WS, Todd KH. Ultrasonography for the initial evaluation of blunt abdominal trauma: a review of prospective trials. Ann Emerg Med 1996; 27:353-361.[Medline]
  25. McGahan JP, Rose J, Coates TL, Wisner DH, Newberry P. Use of ultrasonography in the patient with acute abdominal trauma. J Ultrasound Med 1997; 16:653-662.[Abstract]
  26. Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D, Aprahamian C. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma 1995; 38:879-885.[Medline]
  27. Porter RS, Nester BA, Dalsey WC, et al. Use of ultrasound to determine need for laparotomy in trauma patients. Ann Emerg Med 1997; 29:323-330.[Medline]
  28. Nordenholz KE, Rubin MA, Gularte GG, Liang HK. Ultrasound in the evaluation and management of blunt abdominal trauma. Ann Emerg Med 1997; 29:357-366.[Medline]
  29. Healey MA, Simons RK, Winchell RJ, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful?. J Trauma 1996; 40:875-883.[Medline]
  30. Rothlin MA, Naf R, Amgwerd M, et al. Ultrasound in blunt abdominal and thoracic trauma. J Trauma 1993; 34:488-495.[Medline]
  31. Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling. II. Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990; 30:1427-1429.[Medline]
  32. Hegenbarth R, Rehagel HJ. Ultrasound findings in rupture of the colon after blunt abdominal trauma. Ultraschall in der Medizin 1995; 16:297-298[German].[Medline]
  33. Sherbourne CD, Shanmuganathan K, Mirvis SE, et al. Visceral injury without hemoperitoneum: a limitation of screening abdominal sonography for trauma. Emerg Radiol 1997; 4:349-354.
  34. Gruessner R, Mentges B, Duber C, Ruckert K, Rothmand M. Sonography versus peritoneal lavage in blunt abdominal trauma. J Trauma 1989; 29:242-244.[Medline]
  35. Goletti O, Ghiselli G, Lippolis PV. The role of ultrasonography in blunt abdominal trauma: results in 250 consecutive cases. J Trauma 1994; 36:178-181.[Medline]
  36. Knudson MM, McAninch JW, Gomez R, Lee P, Stubbs HA. Hematuria as a predictor of abdominal injury after blunt trauma. Am J Surg 1992; 164:482-485.[Medline]
  37. Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of abdominal injury in children after blunt trauma. Ann Surg 1988; 208:688-693.[Medline]
  38. Siniluoto TM, Paivansalo MJ, Lanning FP, Typpo AB, Lohela PK, Kotaniemi AE. Ultrasonography in traumatic splenic rupture. Clin Radiol 1992; 46:391-396.[Medline]




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