Some patients have the diagnosis of injury made but are hemodynamically stable with a normal physical examination. This would include patients with a positive DPL or FAST or patients with a CT-diagnosed splenic or hepatic injury. Clearly, some of these patients may be managed nonoperatively. The ability to do so will involve readily available ancillary diagnostic testing such as CT scanning and angiography. This is discussed in more detail below. In smaller centers or community hospitals this may not be realistic. These patients are then best served by surgical exploration. In tertiary care centers some of these patients can be managed nonoperatively.
Special mention must be made of patients with fluid seen on CT scan without a clear source. Some will have hemoperitoneum from a trivial liver or splenic injury that is simply missed on CT. Unfortunately, others will have mesenteric injuries and/or small bowel injuries. Again, in many centers the safest course is to simply explore to avoid late diagnosis of gastrointestinal perforation or ischemia. In tertiary care centers some can be managed nonoperatively by means of careful observation and/or ancillary diagnostics.
The diagnostic dilemma is much less in patients with penetrating trauma. Diagnostic evaluation is undertaken only to infer the presence of abdominal injury. Specific organ injury is diagnosed at the time of surgical exploration. In stab wounds, the presence of hemoperitoneum or suspicion of gastrointestinal injury by physical examination should prompt exploratory laparotomy. A positive local wound exploration is a relative indication for operation. Any patient with a proven transabdominal trajectory following a gunshot wound requires laparotomy.
Some patients with penetrating trauma can be managed nonoperatively. For the most part, this involves patients with injury to the flank and back section. Only 9 percent of such patients who present hemodynamically stable have injuries mandating surgery.15 Diagnostic adjuncts involve contrast-enhanced CT enema using oral, intravenous, and rectal contrast agents (Hgi..252-6). Perivascular hematomas can be investigated further with angiography. Endoscopy of the colon also may provide useful information.
FIG. 252-6. Contrast enhanced CT enema. CT scan with oral, rectal, and intravenous contrast should be performed for asymptomatic patients with injury of flank and back. CT demonstrates a thickened left colon with contrast extravasation.
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