CT vs DPL in blunt abdominal trauma patients
Date First Published:
July 12, 2006
Last Updated:
July 21, 2006
Report by:
Gareth Lock, Medical Student (Manchester Royal Infirmary)
Search checked by:
Gareth Lock, Manchester Royal Infirmary
Three-Part Question:
In [blunt abdominal trauma patients] is [computed tomography scanning better than diagnostic peritoneal lavage] at [identifying intraabdominal injury]?
Clinical Scenario:
A 65 year old patient with Alzheimer's disease presents to the accident and emergency department following a fall. Abdominal injury is suspected. The patient's BP systolic is 96mmHg, pulse rate 110. Is CT scanning more efficacious at diagnosing abdominal injury that diagnostic peritoneal lavage (DPL)?
Search Strategy:
OVID Medline, EMBASE and CINAHL interfaces
Search Details:
{[exp Wounds, Nonpenetrating/ or exp Abdominal Injuries/ or exp Multiple Trauma/ or exp Accidents, Traffic/ orblunt.mp. or crush.mp.] AND [exp Tomography, Spiral Computed/ or exp Tomography, X-Ray Computed/ or CT.mp.] AND [Peritoneal lavage.mp. or exp Peritoneal Lavage or DPL.mp or exp Hemoperitoneum/ or Haemoperitoneum.mp. or Diagnostic peritoneal lavage.mp.]}
Outcome:
OVID Medline -392 papers found of which 6 were relevant to the three part question.
EMBASE - 74 papers found of which none were relevant to the three part question
EMBASE - 74 papers found of which none were relevant to the three part question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma Gonzalez RP. Ickler J. Gachassin P 2001 USA | 252 patients assessed for blunt abdominal trauma via CT alome (125 patients) and DPL +/- CT (127 patients). Results were evaluated in comparison to laparotomy findings | PRCT | False negative scan (CT alone) | 2/125 | No statistics includeed |
| False negative scan (DPL and CT) | 0/127 | ||||
| Economic values | CT arm - $1611 and DPL/CT arm $650 | ||||
| Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. Meyer DM. Thal ER. Weigelt JA. Redman HC. 1989 UK | 301 haemodynamically stable patients who underwent both CT and DPL. Results of CT/DPL were compared to findings on susbsequent laparotomy. | Prospective cohort study. | Negative CT scan | 194/301 (71.6%) | |
| Positive CT Scan | 51/301 (27.1%) | ||||
| False negative CT scan vs positive DPL with postive Laparotomy | 19/194 (9.8%) | ||||
| False negative DPL | 3/194 (1.5%) | ||||
| Evaluation of a diagnostic protocol using screening diagnostic peritoneal lavage with selective use of abdominal computed tomography in blunt abdominal trauma Mele TS. Stewart K. Marokus B. O'Keefe GE 1999 Canada | 167 patients split into two groups - one group that recevies DPL +/- CT (71 patients) and one group that only receives CT (96 patients). Results of CT/DPL were compared to laparotomy findings. | Prospective cohort study. Evidence level 2++ | Missed injuries | 7/96 in the CT only group. 0/71 in the DPL +/- CT group | |
| Time to diagnosis | Average 2.5 hours CT only group. Average 41 minutes in DPL +/- CT group | ||||
| Speed and efficiency in the resuscitation of blunt trauma patients with multiple injuries: the advantage of diagnostic peritoneal lavage over abdominal computerized tomography Blow O. Bassam D. Butler K. Cephas GA. Brady W. Young JS 1998 USA | 1,182 patients admitted during 1994 to an accident and emergency department, 589 of which underwent CT scan, 593 of which underwent DPL +/- CT scan. Results were compared to findings on laparotomy | Prospective cohort study. Evidence level 2++ | Sensitivity | CT 100% DPL 100% | |
| Specificity | CT 99% DPL 98% | ||||
| Positive predictive value | CT 90% DPL 94% | ||||
| Negative predicitive value | CT 100% DPL 100% | ||||
| Accuracy | CT 99.2% DPL 98.4% | ||||
| Cost Analysis | CT $1009 DPL $247 | ||||
| Time to Laparotomy (minutes) | CT 231 +/- 149 DPL 61 +/- 51 | ||||
| A comparison of diagnostic peritoneal lavage and computed tomography (CT scan) in evaluation of the hemodynamically stable patient with blunt abdominal trauma Bell C. Coleridge ST 1992 USA | A total of 545 patients from 6 different prospective cohort studies, all of which underwent either CT or DPL in the evaluation of suspected blunt abdominal injury. Results were compared to laparotomy findings | Systematic review - evidence level 2+ | Averaged sensitvity (DPL) | 96% | 5/6 studies had very small sample sizes. No statistical analysis given. |
| Averaged sensitivity (CT) | 44% | ||||
| Averaged specificity (DPL) | 93% | ||||
| Avergaed specificity (CT) | 96% | ||||
| Complications in evaluating abdominal trauma: diagnostic peritoneal lavage versus computerized axial tomography Davis, J W. Hoyt, D B. Mackersie, R C. McArdle, M S 1990 Dec USA | A review of 2,809 DPLs and 1,331 CT scans performed over a three year period in patients investigated for blunt abdominal trauma. Results of tests compared with laparotomy rates and findings on laparotomy. | Retrospective cohort. Evidence level 2++ | False positive result | DPL (0.1%) CT (0.2%) | Retrospective study No statistics analysis performed. |
| False negative result | DPL (0.3%) CT (1.8%) | ||||
| Complication rate (including technical errors and delays in treatment implementation) | DPL (0.9%) CT (3.4%) |
Author Commentary:
Independantly, DPL results in a high rate on non-theraputic laparotomies. While it has the advantages of rapidity and that fact that it is more cost effective, it cannot accurately diagnose retroperitoneal injury. Similarly, CT scans have been shown to produce more false positive and negative results when performed as the only diagnostic modality. Therefore, many studies advocate the use of the two methods in conjunction with one another.
Bottom Line:
DPL may be used alone in haemodynamically unstable patients, those with concomitant head or chest injuries and those with open fractures. CT should be used in the inital evaluation of haemodynamically stable patients.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Gonzalez RP. Ickler J. Gachassin P. Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma
- Meyer DM. Thal ER. Weigelt JA. Redman HC.. Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma.
- Mele TS. Stewart K. Marokus B. O'Keefe GE. Evaluation of a diagnostic protocol using screening diagnostic peritoneal lavage with selective use of abdominal computed tomography in blunt abdominal trauma
- Blow O. Bassam D. Butler K. Cephas GA. Brady W. Young JS. Speed and efficiency in the resuscitation of blunt trauma patients with multiple injuries: the advantage of diagnostic peritoneal lavage over abdominal computerized tomography
- Bell C. Coleridge ST. A comparison of diagnostic peritoneal lavage and computed tomography (CT scan) in evaluation of the hemodynamically stable patient with blunt abdominal trauma
- Davis, J W. Hoyt, D B. Mackersie, R C. McArdle, M S. Complications in evaluating abdominal trauma: diagnostic peritoneal lavage versus computerized axial tomography