Computed tomography, angiography, and endoscopic retrograde cholangiopancreatography in the nonoperative management of hepatic and splenic trauma.

There is a marked trend toward nonoperative management of abdominal trauma. This has been possible thanks to the advances in imaging and interventional techniques. In this work we review in which way computed tomography (CT) abdominal scans, angiography, and endoscopic retrograde cholangiopancreatography (ERCP) can guide the nonoperative management of hepatic and splenic trauma. The CT abdominal scan with intravenous contrast is the "departure imaging" of choice for the nonoperative management of hepatic and splenic trauma in the hemodynamically stable patient. It is the most accurate test for detecting, defining, and characterizing these injuries, the associated hemoperitoneum, and other abdominal abnormalities (the hollow viscus injuries missed on the CT scan were detected by clinical parameters and had no negative consequences in the outcome). It has an accuracy of more than 95% for these injuries, but CT grading alone cannot decide which patient can be treated conservatively and which patient requires surgery. Its usefulness for follow-up seems challenging. Angiography can be therapeutic, thereby avoiding surgery (some report that angiography can be performed even in patients with active bleeding as damage control); if vessel injury, active bleeding or hemobilia are suspected on the basis of a CT scan in a stable patient, angiography should be carried out. ERCP should be performed in patients with suspected injury to the biliary tree, even with normal iminodiacetic acid radionuclide scanning (HIDA) if symptoms persist. A biliary stent can be placed. Indications for angiography and ERCP remain unclear.