Zingg Tobias, Agri Fabio, Bourgeat Mylène, Yersin Bertrand, Romain Benoît, Schmidt Sabine, Keller Nathalie, Demartines Nicolas
Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
Injury. 2018 Jan;49(1):33-41. doi: 10.1016/j.injury.2017.09.004. Epub 2017 Sep 6.
Significant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury.
Single-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed.
For analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24h occurred. Abdominal tenderness (p<0.0001) and CT grade ≥4 (p<0.0001) were associated with sBBMI, whereas CT grade 4 alone (p=0.93) and WBC count ≥17G/l (p=0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67-99), specificity of 89% (95% CI, 86-91), positive likelihood ratio of 8 (95% CI, 6.1-10), negative likelihood ratio of 0.12 (95% CI, 0.03-0.44), positive predictive value (PPV) of 19% (95% CI, 15-24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7-99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p=0.66).
Diagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.
尽管计算机断层扫描（CT）已广泛应用，但严重钝性肠管和肠系膜损伤（sBBMI）仍常被漏诊。早期治疗可改善此类损伤的预后。本研究旨在评估sBBMI的患病率、延迟诊断的发生率，并测试由白细胞（WBC）计数、是否存在腹部压痛以及肠系膜损伤的CT分级所确定的肠损伤预测评分（BIPS）的性能。
基于登记的单中心回顾性队列研究，筛查2008年至2015年因道路交通事故入住洛桑大学医院创伤中心的所有连续创伤患者。纳入所有接受腹部CT且有可能计算BIPS并具有关于是否存在sBBMI可靠信息的患者进行分析。确定sBBMI患者组中延迟（入院后>24小时）诊断的发生率，并评估BIPS对sBBMI的诊断性能。
为进行分析，纳入了766例具有关于是否存在sBBMI可靠信息的患者。sBBMI的患病率为3.1%（24/766）。在接受CT检查的24%（5/21）稳定创伤患者中，出现了超过24小时的诊断延迟。腹部压痛（p<0.0001）和CT分级≥4（p<0.0001）与sBBMI相关，而单独的CT分级4（p=0.93）和白细胞计数≥17G/l（p=0.30）则不相关。BIPS≥2的敏感性为89%（95%CI，67-99），特异性为89%（95%CI，86-91），阳性似然比为8（95%CI，6.1-10），阴性似然比为0.12（95%CI，0.03-0.44），阳性预测值（PPV）为19%（95%CI，15-24），阴性预测值（NPV）为99.7%（95%CI，98.7-99.9）。单独CT识别出79%（15/19）的sBBMI患者，BIPS识别出89%（17/19）的sBBMI患者（p=0.66）。
尽管常规使用腹部CT，但sBBMI患者的诊断延迟很常见（24%）。在本队列中应用BIPS会导致大量非治疗性腹部探查，且在早期发现sBBMI方面并不比单独使用CT显著更多。
