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MAJ John J. Kelemen, III, MC, USA; LTC R. Russell Martin, MC, USA; CPT James A. Obney, MC, USA; Capt Don Jenkins, MC, USAF; LT Col David P. Kissinger, MC, USAF

Arch Surg. 1997;132(8):909-913.

Abstract
Background
Diagnostic peritoneal lavage (DPL) is used to diagnose intra-abdominal injury in patients with stab wounds and blunt trauma. Because exploratory celiotomy is routinely performed on patients with gunshot wounds to the abdomen, DPL is rarely employed. However, several studies have questioned routine exploration and have drawn attention to the associated morbidity of negative celiotomy. Diagnostic peritoneal lavage is an easily performed and inexpensive test that may be useful in this situation.

Objective
To evaluate the performance of DPL in the diagnosis of intra-abdominal injury in hemodynamically stable patients with gunshot wounds to the abdomen.

Design
A prospective clinical trial.

Setting
Two urban trauma centers.

Patients
Patients with gunshot wounds to the abdomen and a systolic blood pressure of at least 90 mm Hg.

Interventions
Clinical predication of intra-abdominal injury in the emergency department and DPL performed in the operating room before the initiation of celiotomy. Injuries found during the celiotomy were recorded.

Main Outcome Measures
The results of the clinical evaluation and DPL were compared with the findings of the celiotomy.

Results
Forty-four patients were enrolled into the study. Intra-abdominal injury was present in 32 (73%) of these patients. The senior surgery resident correctly predicted the presence of intra-abdominal injury in 36 (82%) of the patients (sensitivity=90.0%, specificity=58.3%, positive predictive value=85.3%, negative predictive value=63.6%,=0.52, P<.01) in the emergency department before DPL and celiotomy were performed. Diagnostic peritoneal lavage correctly identified the presence or absence of intra-abdominal injury in 40 (91%) of the patients (positive predictive value=96.7%, negative predictive value=78.6%,=0.79, P<.01).

Conclusions
Clinical judgment is highly accurate in separating patients with tangential gunshot wounds to the abdomen from those with intra-abdominal injury but may miss patients with intra-abdominal hemorrhage. Diagnostic peritoneal lavage is highly predictive of the presence of intra-abdominal injury. The return of gross blood on aspiration or a lavage red blood cell count greater than 10x109/L should prompt an urgent celiotomy. Missed injuries are rare and most likely to be bowel perforations. Diagnostic peritoneal lavage is an objective test that may augment clinical judgment in selecting hemodynamically stable patients with potential tangential gunshot wounds for observation and is especially useful in identifying intra-abdominal hemorrhage.

Arch Surg. 1997;132:909-913

Author Affiliations
From the General Surgery Services, Brooke Army Medical Center (Drs Kelemen, Martin, and Obney) and Wilford Hall Air Force Medical Center (Drs Jenkins and Kissinger), San Antonio, Tex.

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