Diagnostic Peritoneal Lavage

No Results

No Results

processing….

At one time, diagnostic peritoneal lavage (DPL), described by Root in 1965, ^[1]  was the diagnostic test of choice to detect bleeding within the abdominal cavity after trauma. However, the advent and widespread availability of computed tomography (CT), which carries near-comparable sensitivity and superior specificity, ^[2]  have limited the use of DPL to the diagnosis of intra-abdominal hemorrhage in unstable trauma patients.

Currently, DPL is performed infrequently, having been largely replaced by focused assessment with sonography for trauma (FAST) and CT. The American College of Surgeons (ACS) adopted FAST into the Advanced Trauma Life Support (ATLS) protocol, and the ninth edition of ATLS made DPL an optional skill station, owing to the widespread use of FAST. Still, each of these modalities has unique advantages and disadvantages. DPL retains its usefulness, especially in the hemodynamically unstable trauma patient who has a negative or equivocal FAST examination. (See Technical Considerations.)

DPL can be used to evaluate both blunt and penetrating abdominal trauma in patients who are hemodynamically unstable or who require urgent surgical intervention for associated extra-abdominal injuries. DPL can rapidly confirm or exclude the presence of intraperitoneal hemorrhage. Thus, the patient with a closed head injury, the unstable patient who has been in a motor vehicle accident, or the patient with a pelvic fracture and potential retroperitoneal hemorrhage can be appropriately triaged to emergency laparotomy.

A negative result on peritoneal aspiration allows the clinician to proceed to alternative management steps and allows the patient to forgo unnecessary laparotomy. Additionally, DPL can be used in nonemergency circumstances as a means of detecting solid-organ injury or HVI requiring laparotomy. ^{[3, 4]}

In the evaluation of patients with blunt abdominal trauma or penetrating anterior abdominal stab wounds, DPL provides the following benefits:

Chereau studied DPL in 37 blunt abdominal trauma patients who had one or two CT signs predictive of small-bowel and mesenteric injuries. ^[5] A cell count ratio (CCR) was calculated, in which the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid was divided by the ratio in peripheral blood. DPL was found to have a sensitivity of 100% but a specificity of only 43% for bowel injuries. The authors suggested that diagnosis might be improved by restricting the indications for exploratory laparotomy to patients with a CCR of 4 or higher.

An obvious need for laparotomy is the only absolute contraindication for DPL. Lack of training or familiarity with performing DPL, prior abdominal surgery, abdominal-wall infections, coagulopathy, morbid obesity, and second- or third-trimester pregnancy are all relative contraindications. ^[6]

A positive FAST examination (hemoperitoneum) is useful and reliable in the hemodynamically unstable blunt trauma patient. However, if the FAST examination is negative or equivocal, it should be followed by DPL. DPL is 100% accurate for intra-abdominal injury in hemodynamically unstable patients, whereas FAST is positive only 45% of the time. ^[7]  However, DPL also takes 10-15 minutes, and the patient must be stable for the test to be carried out.

In the hemodynamically stable patient, CT is preferred because it is noninvasive and highly accurate. If CT is unavailable, either FAST or DPL may be used. DPL should also be considered in patients who have an unreliable examination or those at high risk for hollow-viscus injury (HVI), particularly when CT or ultrasonography detects minimal fluid or when the patient manifests fever, peritonitis, or both. This circumstance usually occurs 6-12 hours after an HVI.

DPL, though lacking organ specificity, remains the most sensitive test for mesenteric injury and HVI. FAST is rapid, noninvasive, and can be repeated multiple times; however, it is more user-dependent than DPL or CT. Both FAST and DPL fail to evaluate retroperitoneal and diaphragmatic injuries and poorly identify solid-organ injuries. Abdominopelvic CT requires a hemodynamically stable patient, is costly, and carries a small but significant lifetime risk of malignancy. However, CT reliably diagnoses solid-organ injuries and evaluates the retroperitoneum, but it is less sensitive and specific for HVIs and mesenteric injuries than DPL is. ^[8]

As a result of these differences (see Table 1 below), all three tests continue to play important roles in the evaluation of a trauma patient for abdominal injuries. ^[9]

Table 1. Comparison Parameters for DPL, FAST, and CT (Open Table in a new window)

Parameter

DPL

FAST

CT

Time

10-15 min

2-4 min

Variable

Repeatability

Possible, but rarely done

Easy and frequently done

Yes

Reliability

Not organ specific

Operator dependent

Obesity, movement

Sensitivity

High

Medium

High

Specificity

Low

High

High

Advantages

Inexpensive, mobile, detects bowel injury

Noninvasive, rapid, mobile, moderately expensive (equipment)

Noninvasive, highly accurate, fixed, expensive (equipment)

Disadvantages

Invasive, misses retroperitoneal and diaphragm injuries

Hampered by subcutaneous or intra-abdominal air, obesity, pelvic fractures

Misses diaphragm, small bowel, and pancreatic injuries; radiation

Kumar et al, in a prospective randomized trial comparing DPL (n=102) with FAST (n=98) in 200 consecutive patients (mean age, 28.3 years) who had sustained blunt (n=124) or penetrating (n=76) trauma to the torso, found DPL to be significantly superior to FAST for detecting bowel injuries, though it also took significantly longer to perform. ^[10]

Root HD, Hauser CW, McKinley CR, Lafave JW, Mendiola RP Jr. Diagnostic peritoneal lavage. Surgery. 1965 May. 57:633-7. [Medline].

Meyer DM, Thal ER, Weigelt JA, Redman HC. Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma. 1989 Aug. 29(8):1168-70; discussion 1170-2. [Medline].

Day AC, Rankin N, Charlesworth P. Diagnostic peritoneal lavage: integration with clinical information to improve diagnostic performance. J Trauma. 1992 Jan. 32(1):52-7. [Medline].

Gomez GA, Alvarez R, Plasencia G, et al. Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment. J Trauma. 1987 Jan. 27(1):1-5. [Medline].

Chereau N, Wagner M, Tresallet C, Lucidarme O, Raux M, Menegaux F. CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma. Injury. 2016 Sep. 47 (9):2006-11. [Medline].

Marx JA. Peritoneal procedures. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: WB Saunders; 2004.

Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma. 2009 Aug. 67(2):330-4; discussion 334-6. [Medline].

Ekeh AP, Saxe J, Walusimbi M, et al. Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology–are results better?. J Trauma. 2008 Aug. 65(2):354-9. [Medline].

Gonzalez RP, Ickler J, Gachassin P. Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma. J Trauma. 2001 Dec. 51(6):1128-34; discussion 1134-6. [Medline].

Kumar S, Kumar A, Joshi MK, Rathi V. Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as an adjunct to primary survey in torso trauma: a prospective randomized clinical trial. Ulus Travma Acil Cerrahi Derg. 2014 Mar. 20 (2):101-6. [Medline]. [Full Text].

Marx J, Isenhour J. Abdominal trauma. Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine Concepts and Clinical Practice. 5th ed. St Louis: Mosby; 2006.

Marx JA. Diagnostic peritoneal lavage. Ivatury RR, Cayten CG, eds. The Textbook of Penetrating Trauma. Baltimore: Williams & Wilkins; 1996. 337.

Engrav LH, Benjamin CI, Strate RG, Perry JF Jr. Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma. 1975 Oct. 15(10):854-9. [Medline].

Catapano M, Cwinn AA, Marx JA, Moore EE. Toxic shock syndrome following diagnostic peritoneal lavage. Ann Emerg Med. 1988 Jul. 17(7):736-8. [Medline].

Parameter

DPL

FAST

CT

Time

10-15 min

2-4 min

Variable

Repeatability

Possible, but rarely done

Easy and frequently done

Yes

Reliability

Not organ specific

Operator dependent

Obesity, movement

Sensitivity

High

Medium

High

Specificity

Low

High

High

Advantages

Inexpensive, mobile, detects bowel injury

Noninvasive, rapid, mobile, moderately expensive (equipment)

Noninvasive, highly accurate, fixed, expensive (equipment)

Disadvantages

Invasive, misses retroperitoneal and diaphragm injuries

Hampered by subcutaneous or intra-abdominal air, obesity, pelvic fractures

Misses diaphragm, small bowel, and pancreatic injuries; radiation

Positive

Indeterminate

Blunt trauma

100,000/μL

20-100,000/μL

Stab wound

Anterior abdomen

100,000/μL

20,000-100,000/μL

Flank

100,000/μL

20,000-100,000/μL

Back

100,000/μL

20,000-100,000/μL

Low chest

5000/μL

1000-5000/μL

Gunshot wound

5000/μL

1000-5000/μL

Positive

Indeterminate

Amylase level

≥20 IU/L

10-19 IU/L

Alkaline phosphatase level

≥3 IU/L

NA

White blood cells

>500/μL

250-500/μL

NA = Not applicable.

Liudvikas Jagminas, MD, FACEP Chief of Service, Attending Physician, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Vice-Chair for Network Development, Department of Emergency Medicine, Beth Israel Deaconess and Harvard Medical Faculty Physicians; Adjunct Associate Professor of Emergency Medicine, The Warren Alpert Medical School of Brown University

Liudvikas Jagminas, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, International Trauma Anesthesia and Critical Care Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Darius Jagminas for his rendition of a closed DPL.

Diagnostic Peritoneal Lavage

Research & References of Diagnostic Peritoneal Lavage|A&C Accounting And Tax Services
Source

Share on Facebook

Tweet

Follow us