See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/249313531

Focused Sonography in Detecting Hemoperitoneum in Blunt Abdominal

Trauma Patients, Correlation with Computed Tomography

Article · July 2013

DOI: 10.11648/j.ijmi.20130101.12

CITATIONS READS

0 694

4 authors, including:

Dr Nauman Al Qamari Raza Sayani

Dow University of Health Sciences Aga Khan University Hospital, Karachi
5 PUBLICATIONS   3 CITATIONS    49 PUBLICATIONS   78 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Fellowship thesis. View project

Interpretation of ICU ps imaging View project

All content following this page was uploaded by Raza Sayani on 21 May 2014.

The user has requested enhancement of the downloaded file.

International Journal of Medical Imaging
2013; 1(1): 7-11
Published online July 20, 2013 (http://www.sciencepublishinggroup.com/j/ijmi)
doi: 10.11648/j.ijmi.20130101.12

Focused Sonography in Detecting Hemoperitoneum in

Blunt Abdominal Trauma Patients, Correlation with
Computed Tomography
Nauman Al Qamari1, Raza Sayani1, *, Muhammed Ali2, Muhammad Tamim Akhtar2
1
Radiology Department, Aga Khan University hospital, Karachi, Pakistan
2
Radiology Department, Ziauddin University Hospital, Karachi, Pakistan

Email address:
[email protected](N. Al Qamari), [email protected](R. Sayani), [email protected](M. Ali) ,
[email protected](M. T. Akhtar)

To cite this article:

Nauman Al Qamari, Raza Sayani, Muhammed Ali, Muhammad Tamim Akhtar. Focused Sonography in Detecting Hemoperitoneum in
Blunt Abdominal Trauma Patients, Correlation with Computed Tomography, International Journal of Medical Imaging.
Vol. 1, No. 1, 2013, pp. 7-11. doi: 10.11648/j.ijmi.20130101.12

Abstract: To determine the accuracy of focused assessment with sonography for trauma in detecting the
hemoperitoneum in blunt abdominal trauma patients and comparing it with Computed Tomographic findings. The study
was conducted at Radiology department of Dr. Ziauddin University Hospital from March 2010 to September 2010. 140
patients presented with complaints of acute blunt abdominal trauma. Focused assessment with sonography for trauma was
performed. Presence of intra-abdominal fluid was taken as positive finding for hemoperitoneum. Then all the patients
underwent computed tomography of abdomino-pelvic region. Focused assessment with sonography for trauma findings
were compared with computed tomography results. In 83 patients, the FAST showed free intra abdominal fluid and was
taken as ‘positive’. Out of these 83 cases80 (96%) were ‘true positive’ while the remaining 3(4%) were ‘false positive’
when compared with results of CT scan.Similarly, in 57 patients, no free intra abdominal fluid was detected on FAST and
they were considered ‘negative’. From these 57 patients, 50 (88%) patients were ‘true negative’ and 7 (12%) were ‘false
negative’ because intra abdominal free fluid was seen in them on subsequent CT scan. Thus the sensitivity and specificity
of FAST in detecting intra abdominal free fluid was calculated to be 91.9 % and 94.34 % respectively. FAST scan is
moderately sensitive in detecting intra abdominal free fluid when compared with the results of CT scan.
Keywords: Blunt Abdominal Trauma, Focused Assessment with Sonography for Trauma, Computed Tomography,
Accuracy, Hemoperitoneum

the cause of preventable death.

1. Introduction The abdomen of trauma victims is routinely evaluated
Trauma related injuries continue to be a worldwide with physical examination and clinical signs that have
problem. It is the leading cause of death from ages 15– 44 relatively low diagnostic accuracy (47% to 87%),
in the developed countries, and an ever increasing cause of especially when the patient had a decreased consciousness
death and disability in the developing world. In fact, level, neurological deficit, other associated injuries, or was
traumatic injury may soon outpace infectious diseases as a under the influence of drugs or medications2. Diagnostic
leading cause of worldwide mortality.[1] peritoneal lavage (DPL), ultrasound (FAST), and computed
Abdominal injuries rank third as a cause of traumatic tomography (CT) are typical tests used for abdominal
death just after head and chest injuries. .[2] Historical evaluation in trauma. .[3,4]
records are full of description of blunt abdominal trauma Diagnostic peritoneal lavage has disadvantage of being
victims who turned pale, cold and died without overt invasive technique, hence it is not suitable for conscious
evidence of hemorrhage. Such undetected hemoperitoneum traumatic patients and in pediatric patients. .[5] Ultrasound
was one of the most common causes of death in injured has become a standard of care in most emergency
patients. Unrecognized abdominal injuries are frequently departments. Bedside ultrasonography provides non-
8 Nauman Al Qamari et al.: Focused Sonography in Detecting Hemoperitoneum in Blunt Abdominal Trauma
Patients, Correlation with Computed Tomography

invasive, readily available, and time-saving option for recorded on a written form..
patients with blunt abdominal trauma. [6,7] The term Then all the patients subsequently underwent computed
‘focused abdominal sonography for trauma’ (FAST) scan tomography of abdomino pelvic region. Computed
has been used since the early 1990s. Nowadays, FAST is tomography was performed on multi slice ASTEION 4
the standard practice for blunt abdominal trauma in most (Toshiba, Japan) typically within 30 minutes after FAST.
emergency departments in developed world. Field of examination was from the lung bases to the pelvis
Computed Tomography scan of the abdomen and pelvis with 5 mm contiguous sections and a table speed of
is the procedure of choice to evaluate the hemodynamically 5mm/sec (pitch). CT was routinely performed after contrast
stable patient who has sustained blunt or penetrating trauma. material had been injected intravenously as a power-
CT has replaced Diagnostic Peritoneal Lavage (DPL) as the injected bolus of 140 ml of 240 mg of iodine per milliliter
first method of choice in many trauma centers worldwide at a rate of 3 ml/sec. A uniphasic injection of intravenous
[8,9]. However, it has several disadvantages as it is contrast material with a scan delay of 60 seconds was used.
relatively expensive, involves the usage of ionizing No oral contrast was given. FAST findings were compared
radiation and requires the shifting of patient to the scanner with computed tomography results.
which may interfere with ongoing resuscitation. All information was documented with the help of
Furthermore, it is not always available particularly in small proforma.
peripheral centres. [5, 6, 10].
4. Data Analysis Procedure
2. Objective
All collected information was entered into SPSS version
To determine the accuracy of focused assessment with 10 and analyzed through it. Male to female ratio and mean
sonography for trauma in detecting the hemoperitoneum in standard deviation for age distribution were computed.
blunt abdominal trauma patients and comparing it with Graphs and charts regarding gender, mechanism of trauma
Computed Tomographic findings. and time lapse between trauma and Focused assessment
with sonography for trauma were obtained. A 2x2 table was
3. Materials & Methods constructed and sensitivity, specificity, positive predictive
value, negative predictive value and accuracy of Focused
This is a Cross sectional study, it was carried out at assessment with sonography for trauma in detecting
radiology department of Dr. Ziauddin University Hospital hemoperitoneum in blunt abdominal trauma were
from March 2010 to September 2010. All patients with calculated by using computed tomography findings.
recent blunt abdominal trauma due to road vehicle accident,
fall or violence within last 24 hours who presented to the 5. Results
radiology department were included. Those excluded from
the study were patients who presented more than 24 hours One hundred and forty patients who fulfilled the
after blunt abdominal trauma, who had penetrating inclusion criteria were included in the study. There were 90
abdominal injuries, who were suffering from preexisting (64.29 %) males and 50 (35.71 %) females. The ages of
disease in which there was possibility of presence of intra these patients ranged b/w 1year and 89 years. The mean age
abdominal fluid or those with history of recent abdominal was 33 yrs. Mean ages in male and female patients were
surgery not significantly different.
Patient size was calculated by placing the following Mechanism of injury was motor vehicle accident in 64
values in the formula: Expected sensitivity 0.864, expected patients ( 45 % ), fall from height in 43 patients ( 30 % ),
specificity 0.954, expected prevalence 0.1715, desired assault in 18 patients ( 13 % ) , pedestrian struck in 8
precision 0.12, confidence level 0.90. Sampling Technique patients (6%) and other causes like during playing game in
was non probability, purposive. 7 patients ( 5 % ). Most of the patients included in the study
History was taken in each case about the mechanism and presented within first 12 hrs while about 50 % presented
duration of trauma, preexisting disease and previous within 6 hrs of occurrence of injury. It is shown in chart (1)
surgical history. Informed consent was taken from all the Within 1 hr ______ 5 6 – 12 hrs ________ 40
patients after explaining the purpose, procedure and risks & 1-3 hrs ______ 12 12 – 24 hrs________25
benefits. Approval from the ethical committee of our 3- 6 hrs ______ 58
hospital was taken. Out of 140 patients, in 83 patients the FAST scanning
Focused assessment with sonography for trauma was showed free intra abdominal fluid and was taken positive.
performed on SSD-4000 plus (ALOKA, Japan) with a The most common site where free fluid was detected was
5MHz convex transducer. Intra abdominal free fluid was pelvis and then perihepatic area. In 57 (40%) patients, free
searched in perihepatic and perisplenic regions, Morrison’s fluid was localized in a single region while in other patients
pouch, both para-colic gutters, reteroperitoneum and in more than one pocket of free fluid was found. In 51 patients
pelvis. Presence of intra-abdominal fluid was taken as ( 36% ) free intra abdominal fluid was detected in pelvis ,
positive finding for hemoperitoneum. US results were in 46 patients (33%) it was seen in perihepatic region, in 37
 International Journal of Medical Imaging 2013; 1(1): 7-11 9

( 26% ) it was localized in perisplenic region and in 23 Two other patients were having free fluid due to
patients ( 16% ) free fluid was seen in paracolic gutters. preexisting medical disorder. One was cirrhotic liver with
Figure 1 and 2 .In 5 patients (<1%) hemo pericardium was portal hyper tension and ascites. In other patient, CT scan
detected. confirmed the presence of free fluid in the spleeno-renal
From those 83 FAST positive patients, 80 (96%) were angle, but also showed peri portal and peri cholecystic fluid;
true positive while 3 (4%) were false positive and showed these findings were considered non – traumatic for the
no free fluid on consecutive CT scan. purpose of this study, as they may be due to third spacing of
False positive results may be due to distended, fluid – the fluid related to vigorous fluid resuscitation rather than
filled bowel loops. In one female patient of child bearing injury.
age, free fluid was detected in cul – de – sac in 18th day of The overall sensitivity of FAST was 90.9 % and
menstrual cycle and it was considered to be physiological specificity was 94.23% in this study. Similarly the positive
and taken as negative. predictive value (PPV) was calculated as 96.38% and
FAST scan was unable to detect free intra abdominal negative predictive (NPV) as 85.96% in this study.
fluid in 57 patients and they were taken as FAST ‘negative’. Detection of organ injury was beyond the scope of this
Out of these 57 cases, 49 ( 86%) correlated well with the study, however during interpretation of CT scan about 95
CT scan findings. The remaining 8 (14%) showed free intra patients (68 %) were having organic injuries. Out of these
abdominal fluid on CT scan which was failed to detect on 95 patients, 69 were having grade 1 & 2 liver / splenic
FAST scan. injuries which were managed non – surgically.

Figure 1. Blunt abdominal trauma. Free fluid in the Morison pouch.

Figure 2. Images in a 19-year-old woman involved in a motor vehicle accident. (a) Longitudinal screening US image shows a small amount of fluid
(arrow) near the inferior liver (L) edge. (b) Contrast-enhanced transverse abdominal CT image confirms bowel injury with thickened jejunum (open
arrow) and fluid in the mesentery (black solid arrows) and right paracolic gutter (white solid arrow).

Abdominal injuries are the third common cause of

6. Discussion traumatic death after head and chest injuries[11].
Diagnostic peritoneal lavage (DPL) has been done
10 Nauman Al Qamari et al.: Focused Sonography in Detecting Hemoperitoneum in Blunt Abdominal Trauma
Patients, Correlation with Computed Tomography

historically to detect hemoperitoneum. The introduction of specificity of US relative to CT were 55% and 83%
bedside ultrasonography provides an accurate, non invasive, respectively, and they concluded that US was not accurate
readily available and time saving tool for triage of patient enough to replace CT in this setting.[21] In our study
with blunt abdominal trauma. In this study we focused on sensitivity of sonography is 90.9% and specificity is 94%.
the accuracy of FAST scan in the detection of This is comparable with the study of several previous
hemoperitoneum resulting from blunt abdominal trauma. authors. The present results confirmed that FAST
Further this study also addresses the utility of sonography ultrasound is a sensitive and specific diagnostic tool in the
for identifying injury to specific organs. detection of hemoperitoneum in BAT patient.
Hemodynamically stable patients with positive FAST Some authors have suggested that serial sonogram
results may require a CT scan to better define the nature obtained over time as the peritoneal cavity fills with blood
and extent of their injuries. Taking every patient with a may improve the accuracy of sonography in detecting
positive FAST result to the operating room may result in an hemoperitoneum. Siniluoto et al detected 2 of 5 splenic
unacceptably high laparotomy rate.[12] injuries with initial sonography and identified all 5 injuries
Hemodynamically stable patients with negative FAST 24 hours later using follow up ultrasound.[22] Similarly
results require close observation, serial abdominal Handerson and colleagues reported 4 cases in which
examinations, and a follow-up FAST examination. patients’ initial sonogram were negative for
However, strongly consider performing a CT scan, hemoperitoneum and follow up sonogram obtained on
especially if the patient is intoxicated or has other serial sonography were positive.[23]Poletti and coworker
associated injuries.[13] found that sensitivity improved at second ultrasound by
Hemodynamically unstable patients with negative FAST 15%.[24] Almost similar results were found in present
results are a diagnostic challenge to the treating physician. study in which 8 patients showed free intra-abdominal fluid
Options include DPL, exploratory laparotomy, and, after few hours on serial ultrasound. These results suggest
possibly, a CT scan after aggressive resuscitation.[14,15] that in patients with high clinical suspicion of abdominal
In previous studies, many investigators have reported injury, a repeat ultrasound should be done after few hours
high sensitivity of ultrasound in detecting hemoperitoneum interval to detect small occult hemoperitoneum.
in BAT patients. In 1989 Gruessner and co-workers Solid organs injuries may results in hemoperitoneum that
compared sonography with DPL findings in 808 patients. may not be detected on ultrasound.
The sensitivity and specificity of ultrasonography was Detection of solid organ injury requires more efforts and
reported as 89% and 100% respectively. [16] In a skill than simply searching for free fluid. Some authors
prospective study of 800 patients, Healey calculated the have addressed the potential of ultrasound for the detection
sensitivity of ultrasonography of 88% and specificity of 98% of acute solid injuries. Poletti et al has found that adding
with an overall accuracy of 97%.[17] analysis of parenchymal lesions to analysis of free fluid
In late 1990s Bode analyzed 1,671 consecutive sonogram improved the sensitivity of FAST ultrasound by only 7%
and determined that ultrasonography had a sensitivity of compared with the analysis of free fluid alone (from 65% to
88%, specificity of 100% and an overall accuracy of 72%).[24] Our results are also in agreement with Poletti,
99%.[18] which showed only 2.4% increase ( 2 in 85 patients) in
In a more recent study Lingawi and Buckley evaluated sensitivity after including solid organs assessment along
1,090 patents using focused abdominal sonography FAST with hemoperitoneum.
protocol. Patients with negative sonogram underwent 12 As abdominal trauma is a dynamic event, scanning too
hours of clinical observation followed by repeat ultrasound early might miss a significant abdominal injury as free intra
or computed tomography (CT). Using this approach, their peritoneal fluid need time of accumulate. These results are
reported sensitivity and specificity of sonography were 94% comparable to Tsui CL and colleagues.[25] This can be
and 98% respectively.[19] In 2001, researcher at university demonstrated by one result in which sonographic
of California evaluated 3,264 patient of blunt abdominal sensitivity rose from 60% within 1 hour after BAT to 97%
trauma with sonography and reported sonography in 6 – 12 hours after injury as shown in graph.
sensitivity of 60% in detecting hemoperitoneum, The There were two false positive cases after CT scan in this
specificity and accuracy were 98% and 94% respectively. study. Causes include fluid in cul-de-sac due to ovulation,
Luke et al examined 259 children admitted for blunt fluid in the stomach or dilated bowel and visualization of
abdominal trauma who underwent ultrasound and their perinephric fat. Almost similar causes were described by
calculated sensitivity, specificity, and accuracy for several authors.
detection of hemoperitoneum were 89%, 96% and 94%
respectively.[20] 7. Limitations
These studies suggest that sonography is sensitive and
highly specific for the detection of hemoperitoneum in BAT Our study is hampered by certain limitations. First of all
patients. However few researchers have reported decreased the severity of hemodynamic instability of patient was not
sensitivity of sonography. Coley and co-workers compared assessed in our study. Similarly, by focusing only at the
US with CT and determined that the sensitivity and detection of hemoperitoneum, we could not successfully
 International Journal of Medical Imaging 2013; 1(1): 7-11 11

triage patient for surgery and laparotomy after sonographic Injury2005;36:970-5.

assessment and these decisions were usually made after CT [11] Farahmand N, Sirlin CB, Brown MA, Shragg GP, Fortlage
scanning. D, Hoyt DB et al. Hypotensive patients with blunt
abdominal trauma. Performance of screening ultrasound. J
Radiology 2005;235:436-43.
8. Conclusion
[12] Richards JR, Schleper NH, Woo BD, Bohnen PA, McGahan
We conclude that FAST scan is a useful diagnostic tool JP. Sonographic assessment of blunt abdominal trauma:
in the initial assessment of blunt abdominal trauma patients. a 4-year prospective study. J Clin Ultrasound 2002; 30:59-
It is accurate with high specificity and positive predictive 67. 3
value. The high negative predictive value makes it a useful [13] Griffin XL, Pullinger R. Are diagnostic peritoneal lavage or
screening tool for detecting hemoperitoneum. focussed abdominal sonography for trauma safe screening
Serial sonography can improve overall sensitivity of investigations for hemodyamically stable patients after blunt
FAST scan and should be done in all patients with high abdominal trauma. A review of the literature. J Trauma
clinical suspicion of visceral injury and negative early 2007;62:779–84
ultrasound. [14] Sirlin CB, Brown MA, Andrade-Barreto OA. Blunt
Ultrasound is limited mainly by its low sensitivity in abdominal trauma: clinical value of negative screening US
directly demonstrating solid organs injuries. scans. Radiology 2004; 230:661–668.

[15] Stengel D, Bauwens K, Sehouli J. Systematic review and

meta-analysis of emergency ultrasonography for blunt
Refrences abdominal trauma. Br J Surg. 2001; 88: 901-912

[1] Krug EG, Sharma GK, Lozano R: The global burden of [16] Gruessner R, Mentges B, Duber CH, Ruckert K, Rothmund
injuries. Am J Public Health 2000, 90:523-526. M. Sonography versus peritoneal lavage in blunt abdominal
trauma. J Trauma 1989;29:242–4.
[2] Perry JF. A Five-year survey of 152 acute abdominal injuries.
J Trauma 1965; 5:53–57. [17] Healey MA, Simons RK, Winchell RJ. A prospective
evaluation of abdominal ultrasound in blunt trauma: is it
[3] Elton C, Riaz AA, Young N, Schamschula R, Papadopoulos useful? J Trauma 1996;40:875–83.
B, Malka V. Accuracy of computed tomography in the
detection of blunt bowel and mesenteric injuries. Br J Surg [18] Bode PJ, Edwards MJ, Kruit MC, Van Vugt AB.
2005;92:1024-8 Sonography in a clinical algorithm for early evaluation of
1671 patients with blunt abdominal trauma. AJR Am J
[4] Ochsner MG, Knudson MM, Pachter HL, Hoyt DB, Cogbill Roentgenol 1999; 172:905-911.
TH. Significance of minimal or no intraperitoneal fluid
visible on CT scan associated with blunt liver and splenic [19] Lingawi S, Buckley A. Focused abdominal US in patients
injuries: a multicenter analysis. J Trauma 2000;49:505–10. with trauma. Radiology 2000; 217:426–429.

[5] Nural MS, Yarden T, Guven H, Baydin A, Bayrak IK, Kati C. [20] Luks FI, Lemire A, St-Vil D, Di Lorenzo M, Filiatrault D,
Diagnostic value of u/s in evaluation of blunt abdominal Ouimet A. Blunt abdominal trauma in children: the practical
trauma. Diagn Interv Rad 2005;11:41-4. value of ultrasonography. J Trauma 1993;34:607–10.

[6] Kristensen JR, Bueman B, Keuhl E. Ultrasonic scanning in [21] Coley BD, Mutabagani KH, Martin HC, Zumberge N,
the diagnosis of splenic haematomas. Acta Chir Scand Cooney DR, Caniano DA et al. Focused abdominal
1971;137:653–657 sonography for trauma (FAST) in children with blunt
abdominal trauma. The Journal of Trauma 2000;40(5):902-5.
[7] Kirkpatrick AW. Clinician-performed focused sonography
for the resuscitation of trauma. Crit Care Med [22] Siniluoto TM, Paivansalo MJ, Lanning FP, Typpo AB,
2007;35:S162-72. Lohela PK, Kotaniemi AE. Ultrasonography in traumatic
splenic rupture. Clin Radiol 1992;46:391–6.
[8] Bakker J, Gender R, Mali W, Leenen L. Sonography as the
primary screening method in evaluating blunt abdominal [23] Henderson SO, Sung J, Mandavia D. Serial abdominal
trauma. Journal of Clinical Ultrasound 2005;33:155-63. ultrasound in the setting of trauma. J Emerg Med
2000;18:79–81.
[9] Tso P, Rodriguez A, Cooper C, Militello P, Mirvis S,
Badellino MM, et al. Sonography in blunt abdominal [24] Poletti PA, Kinkel K, Vermeulen B, et al. Blunt abdominal
trauma: a preliminary progress report. J trauma: should US be used to detect both free fluid and
Trauma. Jul 1992;33(1):39-43; discussion 43-4. organ injuries? Radiology. 2003; 227:95-103.

[10] Soundappan SV, Holland AJ, Cass DT, Lam A. Diagnostic [25] Tsui CL, Fung HT, Chung KL, Kam CW. Focused
accuracy of Surgeon performed focused abdominal abdominal sonography for trauma in the emergency
sonography (FAST) in blunt pediatric trauma. department for blunt abdominal trauma. Int J Emerg
Med2008;1:183-7.

View publication stats