The use of oral contrast, with CT, in acute abdominal trauma
Date First Published:
April 16, 2010
Last Updated:
June 17, 2010
Report by:
Annabel Fletcher, ST3 in Emergency Medicine (Plymouth Hospitals NHS trust)
Three-Part Question:
[In patients presenting to the emergency department with blunt abdominal trauma] is [there a place for oral contrast, in conjunction with CT] in [identifying life threatening intra-abdominal pathologies]
Clinical Scenario:
A 19 year-old girl was brought in having fallen off her horse at a canter and kicked in the abdomen. An ED trauma call was initiated. She was alert, orientated, stable but tachycardic. She had external bruising to her abdomen and it was tender on palpation, a training FAST scan was negative. Analgesia was given and the tachycardia remained. A CT abdo was requested. The consultant radiologist insisted that oral contrast was given. I wondered whether giving oral contrast improved images and diagnosis enough to outweigh the delay to scan as well as the hazards of giving oral contrast.
Search Strategy:
Medline 1950/10 using the OVID interface.
Search Details:
{exp abdominal injuries AND exp Tomography, X-ray Computed AND exp Contrast Media} LIMIT English language and humans
Outcome:
There were 18 articles which I read through, of which seven were relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Oral contrast Solution and Computed Tomography for Blunt Abdominal Trauma, A Randomised Study Stafford RE, McGonigal MD, Weigelt JA, Johnson TJ. 1999 USA | 394 patients with blunt abdominal trauma. Average age 36 years. Oral contrast (OC) vs no OC. |
RCT | Nausea and vomiting | Vomiting in 12.9%: no change between groups | Small numbers of small bowel injuries. Limited study power. |
| Abnormal CT results | 105 abnormal scans (50 OC and 55 no-OC) | ||||
| Need for laparotomy | 33 abnormal scans had laparotomies (19 OC vs. 14 no OC). One scan per group was non-therapeutic | ||||
| Missed GI tract and solid organ injuries | 1 missed Small bowel injury in non-OC group (sensitivity 86%), non missed in OC group (100%). Sensitivity for solid organ injury 84% OC, 88.9% non-OC. Specificity for solid organ injury was 94% OC group and 57.1% no-OC group | ||||
| Time to Scan | Time to scan 39.02+/-18.73 mins with no OC, 45.92 +/- 24.17 mins in OC group | ||||
| Computed Tomographic Scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH 2004 USA | 500 consecutive adult, blunt ‘trauma 1’ patients from July 2000- November 2001. All imaged with iv contrast not oral | Diagnostic cohort | Blunt bowel & mesenteric injuries (BBMI) diagnosed on CT. True BBMI diagnosed at laparotomy or autopsy. | 20 patients had True BBMIs . 19 of these patients were identified on CT. Sensitivity 95%. There was 1 false negative. 480 patients proved to have no injury to the bowel or mesentery. 478/480 were identified on CT. Specificity 99.6%. There were 2 false positives. | retrospective small numbers with pathology |
| 3 month follow up phone call | No patients found to have missed injury at the 3 month follow up call | ||||
| Effect of oral contrast administration for abdominal computed tomography in the evaluation of acute blunt trauma Tsang BD, Panacek EA, Brant WE, Wisner DH 1997 USA | 124 patients notes from 2192 who presented with abdominal trauma and had an abdominal CT, admitted between 1st June 1988 and 1st Nov 1993. Age 28 +/- 15.7 years |
Diagnostic cohort | the frequency at which OC contributes to diagnostic value of abdo CT for trauma. The value of OC in intestinal and pancreatic injuries. | All spleen and liver injuries were correctly diagnosed prospectively by CT. All these could have been diagnosed in the absence of OC. All patients sent home with no intra-abdominal injury had CTs read as normal. OC judged essential in none. 1 of 22 intestinal/mesenteric injuries was diagnosed on CT. It was judged that this case could have been seen without OC. The other 21 were diagnosed surgically, none were diagnosed prospectively by CT. No CT scans showed free air or contrast extravasation in the 7 cases of intestinal perforation. Only 2 CTs were found in which OC was thought to be essential. Both with Pancreatic injuries. (one was a false positive result though). There were two other pancreatic injuries diagnoses at laparotomy and these had normal CTs. | Retrospective study Selection bias (from the surgeons) Volume of OC used was large (1000ml) This study used subjective ‘professional opinion’ as the main judgement, retrospectively, of whether OC was necessary or not. They included patients aged 7 weeks to greater than 65 years |
| the delay to CT with OC | CT was delayed by an average of 2 hours with the OC. | ||||
| the SE of OC administration | OC had SE- placements of NGTs, vomiting and aspiration | ||||
| Blunt abdominal Trauma: Performance of CT without Oral contrast material Stuhlfault JW, Soto JA, Lucey BC, Ulrich A, Rathlev NK, Burke PA, Hirsch EF 2004 USA | CT reports (Oct 01- Sept ’03), from 1082 adult (18 years or older) patients, were reviewed. 765 men/ 317 women (no patients received OC) |
Diagnostic cohort |
Negative CT findings | 932 patients had a normal CT scan (i.e. no intra-abdominal injury seen). 1 patient in this group went on to have surgery for a perforation (not visible on CT) i.e. 1 false negative | Retrospective small numbers with intra-abdominal pathologies. |
| Solid organ injury with or without haemoperitoneum | 102 patients had solid organ injury with or without haemoperitoneum. 26 of these patients required surgery. 25/26 showed no viscera/mesenteric injury at laparotomy. | ||||
| CT showing only free fluid | 34 patients showed free fluid. 21 managed conservatively, 7 had surgical exploration (no injury identified), 6 had repeat CT with OC within 48 hours of admission (one had negative laparotomy others no change) | ||||
| CT considered suspicious for bowel or mesenteric injury | 14 CTs were suspicious for bowel or mesenteric injury. At laparotomy 9/14 patients had confirmed injuries. (5 false positives) | ||||
| Followed these CT diagnoses through hospital course to find out sensitivity and specificity of CT without OC. | 1066 true negatives,9 true positives, 2 false negatives, 5 false-positives on CT interpretation. Sensitivity for MDCT for identification of bowel or mesenteric injury requiring surgical repair was 82%. Specificity was 99%. Positive predictive value 64%. Negative predictive value 99% | ||||
| Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children Shankar KR, Lloyd DA, Kitteringham L, Carty HM. 1999 UK | 101 children (72 boys, 29 girls) who had abdominal trauma between 1993- 97. Median age 9.5 (range 1.5- 16.5) notes review | Diagnostic cohort |
Abdominal CT was positive if there was evidence of solid organ injury, intraperitoneal fluid of air, retroperitoneal haematoma. | 57 (vs. 44) patients received OC. 3 children then received contrast in a further scan. 34 children had positive CT scans. 30/34 had solid organ injury. 3/30 required laparotomy (which confirmed CT findings). 2/60 suspected intestinal injury on CT (OC), 1/2 had injury at laparotomy. 2/44 suspected intestinal injury on CT (no OC), 2/2 had injury at laparotomy. 1 child had 2 negative CTs (1 without then the 2nd with OC). Laparotomy done (clinical findings) and showed perforation. | Medical records review Small numbers in some groups retrospective |
| Oral Contrast is not necessary in the evaluation of Blunt abdominal trauma by computed tomography Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG 1993 USA | 492 identified from Trauma registry who had CTs for blunt trauma between Jan 1988 and Dec 1991 65% male Mean age 32.2 OC used in 8 patients (2%) |
Diagnostic cohort |
Operative procedures | 372 patients had negative CT scans. 1 missed bowel injury (76%). 120 patients had positive scans (24%). 42 had abdominal surgery; 2 correctly diagnosed bowel injury and 2 false negative bowel injuries (of note during laparotomy there were 4 previously unseen injuries identified). 78 patients (with positive scans) had no abdominal surgery and there were no late bowel injuries in this group. | retrospective no real comparison between no-OC and OC CT defined outcome measures such as LOS and mortality but did not really discuss these or go into much detail. |
| Length of stay (LOS) | LOS significantly longer among survivors. | ||||
| mortality | 37 deaths (7.5%)- 29 of which were caused by Head Injury. | ||||
| false negative and false positive scans | Sensitivity CT scan 98.4%. Specificity CT scan 99.8% | ||||
| Traumatic diaphragmatic rupture: can oral contrast increase CT detectability? Koroglu M, Ernst RD, Oto A, Mileski WJ 2004 USA | A single case report of a 37 year old man. MOI- RTC |
Case Report | Surgery | This patient had a CT with iv but no oral contrast which was negative for intra abdominal pathology. A second CT with oral contrast then occurred which showed a diaphragmatic rupture and he underwent surgery. He remained haemodynamically stable throughout. | single case |
Author Commentary:
The difficultly with this BestBET is that there have been huge advancements in CT now which make the scanning techniques, of even a few years ago, almost obsolete. I guess the reassuring thing though is that even in the older papers, without our new MDCT-ways, there was no place, in the acute presentation, for the use of oral contrast prior to CT. All studies suffered from a low incidence of intra-abdominal pathologies.
Bottom Line:
MDCT alone is an excellent negative predictor. The use of oral contrast with CT, in the acute setting, in patients with blunt abdominal trauma, is not indicated.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Stafford RE, McGonigal MD, Weigelt JA, Johnson TJ. . Oral contrast Solution and Computed Tomography for Blunt Abdominal Trauma, A Randomised Study
- Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH. Computed Tomographic Scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma
- Tsang BD, Panacek EA, Brant WE, Wisner DH. Effect of oral contrast administration for abdominal computed tomography in the evaluation of acute blunt trauma
- Stuhlfault JW, Soto JA, Lucey BC, Ulrich A, Rathlev NK, Burke PA, Hirsch EF. Blunt abdominal Trauma: Performance of CT without Oral contrast material
- Shankar KR, Lloyd DA, Kitteringham L, Carty HM. . Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children
- Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG. Oral Contrast is not necessary in the evaluation of Blunt abdominal trauma by computed tomography
- Koroglu M, Ernst RD, Oto A, Mileski WJ. Traumatic diaphragmatic rupture: can oral contrast increase CT detectability?