European Journal of Cardiovascular Medicine

Trauma has been aptly described as an unsolved epidemic of modern society, with mortality comparable to that from cardiovascular disease and cancer combined. It remains the leading cause of death in people under 40 years, with abdominal trauma accounting for ~10% of cases. Abdominal injuries are classically divided into blunt trauma and penetrating trauma. Blunt abdominal trauma (BAT), most often due to road traffic accidents, falls, or sports, may pose an immediate life threat, making rapid diagnosis essential as trauma is a time-sensitive disease. Reported prevalence of intra-abdominal injury ranges from 7.7% to 65%.^1,2

Unstable patients suspected of intra-abdominal injury undergo immediate surgical exploration, whereas in stable patients accurate diagnosis is critical for timely therapy. Clinical examination alone is often unreliable due to confounding factors such as alcohol, head injury, or altered sensorium, necessitating objective diagnostic tools.3,4

Historically, plain radiography, contrast studies, angiography, scintigraphy, and diagnostic laparotomy were used. Though laparotomy was once the standard, its morbidity and mortality led to a shift toward selective, non-operative management. Diagnostic peritoneal lavage (DPL), introduced in 1965, provided a rapid, inexpensive, and sensitive method but was limited by its non-localizing nature and inability to assess retroperitoneal organs.^5,6

Plain radiography today has limited value, mainly in detecting associated thoracic or pelvic injuries. Ultrasonography (US), first applied in BAT in 1971, is now the primary screening tool in many trauma centers. Focused Assessment with Sonography for Trauma (FAST) rapidly detects intraperitoneal fluid, is portable, inexpensive, non-invasive, and allows evaluation without interrupting resuscitation.^7,8

Computed tomography (CT), introduced in the 1980s, is the investigation of choice in hemodynamically stable patients. CT provides a comprehensive view of intra-abdominal and retroperitoneal structures, helps in management decisions, and has reduced non-therapeutic laparotomies by enabling safe conservative management of solid-organ injuries. Limitations include insensitivity to early bowel or pancreatic injury, the need to shift patients, time requirements, and cost/availability.^9,10.

A prospective study of 31 hemodynamically stable patients with suspected BAT (Blunt abdominal trauma) was conducted between June  2022 and June 2024 , Arundathi Institute of Medical Sciences , Dundigal ,Medchal, Hyderabad, Telangana. All patients underwent plain X-ray, US, and CT.  Organ injuries were staged according to the Organ Injury Scaling (OIS) system. Diagnostic accuracy of each modality was correlated with operative findings and clinical outcomes were included. Clinical details such as time, cause, and mode of injury were recorded whenever available.

Inclusion Criteria

• Patients presenting to the Casualty Department of Prathima Institute of Medical Sciences with suspected blunt abdominal trauma (BAT).
• Hemodynamically stable patients who could safely undergo all three imaging modalities: X-ray, ultrasonography (US), and computed tomography (CT).
• Patients in whom at least one imaging modality (X-ray, US, or CT) demonstrated positive findings suggestive of intra-abdominal injury.
• Patients in whom clinical details regarding time, cause, and mode of injury could be obtained (whenever possible).

Exclusion Criteria

• Patients with all three imaging modalities interpreted as negative.
• Patients who were hemodynamically unstable and therefore could not undergo all three imaging modalities.
• Patients with incomplete data or inconclusive imaging studies preventing adequate comparison.

Plain Radiography:X-rays were performed on a Philips Carestream GE DR System in the upright (erect abdomen) and left lateral decubitus positions. Special emphasis was given to the detection of:

• Free intraperitoneal air (pneumoperitoneum)
• Air–fluid levels

Ultrasonography (US):Ultrasound examinations were performed using Philips Affiniti 70 & 30 G systems, with 2–5 MHz curvilinear and 5–10 MHz linear probes. The evaluation focused on:

• Detection of free intraperitoneal or pelvic fluid
• Assessment of visceral organs for parenchymal abnormalities such as hematomas, lacerations, or zones of echo textural heterogeneity
• Gall bladder and urinary bladder were assessed for distension, wall abnormalities, and intraluminal echoes

Computed Tomography (CT):CT scans were performed using a Philips Ingenuity 128-slice helical scanner.

Contrast protocol:

• No routine oral contrast was given
• All patients received 100 ml of 60% non-ionic iodinated contrast intravenously at 2–4 ml/sec via an 18–20 G peripheral line using an automated Medrad Power Injector
• Scanning began 70–90 seconds after contrast infusion
• Delayed CT scans were obtained when renal or urinary tract injury was suspected
• Additional lung and bone window reconstructions were performed when required
• Free fluid with attenuation values >30 Hounsfield Units (HU) was labeled as hemoperitoneum. Follow-up US or CT was performed as dictated by clinical course.

• Statistical Analysis:The findings of X-ray, US, and CT were correlated with operative and clinical outcomes. Sensitivity, specificity, and accuracy of each modality were calculated for the detection of intra-abdominal injuries.

31patients with a history of blunt abdominal trauma were evaluated by each of X-Ray, US and CT. There were 24 male and 7 female patients. The age of patients ranged from 8 years to 75 years. The mean age was 37.9 years. One patient was children (< 12 years). Fourteen patients were 40 years or older.

Out of the total 31 patients, one patient presented with penetrating injury along with blunt trauma due to assault. The rest of the patients had blunt injury by various mechanisms

The shortest time of presentation was 1 hour and the longest time of presentation since injury was 1 day. Only eight patients were seen within four hours after injury. Of the total, 27 patients were scanned within 12 hours and 4 were scanned after more than 12 hours following injury.

Indication for imaging: -for suspected liver or splenic injury (n = 27). In eighteen patients, imaging was requisitioned to rule out intra-abdominal injury. Six patients were evaluated for complaints of hematuria.

Hemoperitoneum was detected on US in 26 and CT in 30 patients and was the commonest finding. Hemoperitoneum detected on US was scored according to the scoring system developed by Huang et al.39 (1994). They were divided into two groups. Those scoring less than 3 points (n = 10), and those scoring 3 or more points (n = 16). Outcome of the two groups was analyzed

In the group with US score less than 3, six out of ten patients required a therapeutic laparotomy (45.4%). In contrast twelve out of sixteen required operative management (80%) in the other group with US score 3 or more.

30 detected to have hemoperitoneum on CT were classified as small (n=6), moderate (n=19), and large (n=5), according to the system described by Federle and Jeffrey. Outcome of these three groups was analyzed (Flow chart 2). US correctly detected free intraperitoneal fluid in 26 of the 30 patients with hemoperitoneum, out of the total number of 31 patients. There was no false positive case in US. US detection of free intraperitoneal fluid thus had a sensitivity of 83.8%, specificity of 100% and an accuracy of 84%.

A total of 20 (64.5%) patients had surgical management including two cases of non-therapeutic laparotomy. The remaining 11 (35.4%) were managed conservatively.

Table 1: Distribution of organ injuries

Out of the total 31 patients, in 14 patients US and CT showed similar findings. In 15 patients CT detected additional finding or provided additional information but did not change the management. In 4 patients CT was decisive for management or surgical planning. However in all of them US showed the presence of free fluid.

In 30 patients US showed either intra-abdominal free fluid or organ injury or both. In one patient US did not reveal any abnormality. Liver injury was later detected on CT.US had an overall sensitivity of 96%, specificity of 100% and accuracy of 96%.CT was positive (either for intra-abdominal free fluid or organ injury or both) in all the patients and thus showed an overall sensitivity, specificity and accuracy of 100%.

CT showed distinct advantage in patients with overlying subcutaneous emphysema which prevented normal visualization of underlying structures on US (in case no.15). The patient had splenic injury. CT was useful in detecting associated injuries such as hemothorax-5 cases (16%), pneumothorax- 1(3.2%), lung contusions-1 cases (3.2%), rib fractures -8 cases (25.8%), vertebral fractures-1 cases (3.2%), and pelvic fractures-6 cases(19.3%) thereby providing additional information in guiding the initial mode of management of such patients

In most studies, the major mechanisms of injury are road traffic accidents (RTA), followed by fall. In the present study RTA accounted for 77.4% of injuries and 19.3% of patients sustained injuries due to fall from height. The prevalence of trauma was more in males (77%) as reported in earlier studies. Of the total 31 patients, free intraperitoneal air under the diaphragm was seen in 2 patients on abdominal radiograph and three on CT which were managed surgically. All the three had associated bowel injury and one had renal injury which were later detected on CT. Pneumoperitoneum does not always indicate bowel rupture and can be observed in patients with pneumomediastinum or pneumothorax and in patients on mechanical ventilation. In our study X-Ray showed an overall sensitivity, specificity and accuracy of 33%, 100%& 60% respectively and CT accurately diagnosed all the three cases. The sensitivity of 33% in our study is similar to that found by Stapakis JC et al.¹¹in detecting free air on abdominal radiograph in comparison with CT. Radwan et al.¹²(2006), evaluated the role of FAST and CT in BAT patients. They suggested that FAST is useful as an initial diagnostic tool to detect intra- abdominal fluid. In our study of total 31 patients, US showed good detection of free fluid in 26 patients.

CT plays a crucial role in abdominal trauma due to its high accuracy in identifying injuries that require early surgical intervention and in grading injury severity to guide management. It reduces negative laparotomies by distinguishing cases suitable for conservative treatment. While US is sensitive, widely available, and useful as an initial tool, it is operator-dependent and limited in detecting retroperitoneal and bowel injuries. CT, though less available, is diagnostically superior and can simultaneously evaluate associated injuries. Hemodynamic instability, altered consciousness, or major associated injuries highlight the need for rapid and accurate imaging, often making CT the investigation of choice when feasible. 

In the present study, the age group which was mostly affected was between 16-45 years. This is probably because this age group normally leads an active life outdoors. People around 50 years or older have a lesser active life outdoors. However, this age was not a significant aspect for occurrence of abdominal trauma. Neither was the gender. Males are normally active outdoors, and susceptible to accidents compared to the women. In our study male predominance (77.4%) was found.

Table-2:Comparision of free intraperitoneal fluid detection on us by various studies

 US could correctly detect the source of hemoperitoneum in 21 out of 26 patients with free fluid on US (80.7%). CT detected the source of hemoperitoneum in all but one of the 31 patients (sensitivity of 100%). The patient had a small hepatic injury.

Hemoperitoneum: Hemoperitoneum was the most frequent sign of abdominal injury, detected in 30/31 patients on CT (96.7%) and 26 patients on US (83.8% sensitivity, 100% specificity, 84% accuracy). It was most common with liver, spleen, and bowel injuries, with the liver being the leading source. CT reliably identified hemoperitoneum (>30 HU), whereas US false negatives were likely due to delayed bleeding. Our findings are comparable to Boutros et al.17 (93% sensitivity, 99% specificity with FAST) and Mallik et al.18 (2000).

Spleen: The spleen was the second most frequently injured organ in this study (41.9% on CT; 32% overall incidence). US detected 7 cases (22%), while CT detected 13 cases (41.9%), including 6 missed by US. US showed 58.3% sensitivity and 100% specificity, lower than Mallik et al.18 (73% sensitivity, 100% specificity) and Asher et al.19 (80% sensitivity). False negatives were mostly due to diaphragm or overlying emphysema. CT diagnosed all splenic injuries accurately with no false positives.

Liver: The liver was the most frequently injured organ in blunt trauma (54.8% incidence), consistent with its size and vascularity. US detected 14 cases (45%), while CT detected 17 cases (54%). US demonstrated 83% sensitivity, 100% specificity, and 84% accuracy, performing better for hepatic than splenic injuries. CT was again the most reliable tool for detection and grading.

Liver: The most frequently injured organ in our study (54.8% incidence). US detected 14/17 cases with 83% sensitivity, 100% specificity, 84% accuracy, consistent with Goletti et al.20 (80/100%), Mallik et al.18(100% retrospective), and Srivastava et al. 21(81.2/97%). CT detected all cases, accurately depicting extent and guiding management.

Kidneys: Renal injuries occurred in 9.6% of patients. US detected only 1/3 cases (33.3% sensitivity, 100% specificity, 60% accuracy), while CT diagnosed all three, graded them, and revealed associated multi-organ injuries. All false-negative US cases required surgery.

Pancreas: Two patients (6.4%) had pancreatic injuries. US detected only free fluid, not parenchymal changes. CT correctly diagnosed both, showing hypodensities in the head/neck and tail. All were managed conservatively. Diagnostic difficulty is well recognized, with repeat CT (12–24h) often advised if suspicion persists.

Bowel: Bowel injuries occurred in 16%, making it the third most common injury. US had poor sensitivity (20%) versus CT (100% sensitivity and accuracy). Our results align with Stuhlfaut et al22. (82% sensitivity, 99% specificity) and Liu et al., who emphasized CT’s superiority in detecting small bowel perforation and retroperitoneal hematomas.

Bladder: One patient had extraperitoneal rupture (posterior wall, grade II), detected only on CT, which showed contrast extravasation on delayed scans. CT is considered more sensitive than cystography for small leaks.

Diaphragm: One patient (3.2%) had left hemidiaphragm rupture with associated splenic injury. US was non-diagnostic due to subcutaneous emphysema, while CT confirmed the injury.

Retroperitoneal Hematoma & Pelvic Fractures: Six patients had pelvic fractures; one had an associated retroperitoneal hematoma, detected only by CT. Prior studies (Mallik et a¹⁸l., Liu et al²³.) also confirm CT’s superiority, as US often misses such lesions.

Table-3: Comparison of results of us in different studies in patients with abdominal trauma

Overall Diagnostic Value of US and CT:
Taking free fluid or organ injury as positive, US had 96% sensitivity, 100% specificity, and 96% accuracy, consistent with prior studies. Free intraperitoneal fluid was a frequent marker, but laparotomy decisions in our study were based on clinical and overall imaging assessment, unlike Huang et al., who operated routinely for scores ≥3. In our series, 60% with scores <3 and 75% with scores ≥3 required laparotomy, though a quarter with higher scores were still managed conservatively, reaffirming that hemodynamic stability is the main determinant of management.

Correlation of Free Fluid and Outcome:
CT quantification of hemoperitoneum correlated well with outcome: large collections always required surgery, most small collections were managed conservatively, and moderate collections had mixed outcomes.

Non-therapeutic Laparotomy:
Our study showed an 8.3% incidence, similar to Mallik et al. (8.5%), but higher than Goletti et al. (2.4%). Literature reports a range of 0.8–15.4%. Minimizing unnecessary laparotomy remains important, though avoiding missed critical injuries is paramount.

Impact of CT:

• In 45%, US and CT showed similar findings.
• In 48%, CT added information without altering management.
• In 12.9%, CT findings were decisive, detecting bowel, renal, and additional injuries that influenced surgery.
  If US alone had been relied on, 18 false negatives would have resulted in 6 missed injuries requiring surgery. Missed lesions included splenic, hepatic, renal, pancreatic, bowel/mesenteric, diaphragmatic, bladder, and retroperitoneal injuries.

Organ Injury Grading and Outcome:

• Spleen: Grade I injuries managed conservatively; Grades II–IV required surgery.
• Liver: Most Grade I–III injuries managed conservatively, but surgery required in multi-organ cases, consistent with Boone et al. (1995).
• Kidneys: Injury grade did not predict outcome; all required surgery when associated with multi-organ trauma.

Other Injuries:
CT also demonstrated pelvic and spinal fractures, though major vascular injuries were not observed, likely because such patients were unstable and taken directly for laparotomy.

In 31 patients with blunt abdominal trauma, US and CT proved highly effective, while plain X-ray had minimal value.

X-ray: Sensitivity 33%, specificity 100%, accuracy 60% → limited role in detecting intra-abdominal bleeding or organ injury.

Ultrasonography (US): Overall sensitivity 96%, specificity 100%, accuracy 96% → valuable as the initial screening tool, but limited by operator dependency, bowel gas, and emphysema.

Computed Tomography (CT): Sensitivity, specificity, and accuracy all 100% → the definitive modality, essential for defining the extent of injury, excluding missed lesions, and guiding management.

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